Notice of HIPAA-Privacy Practices
Ian Vassilaros, LPC, LPCC, LLC

This notice describes how mental health information about you may be used and

disclosed and how you can get access to the information.

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Please review it carefully.

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I. Uses and Disclosures for Treatment, Payment and Health Care Operations

Your protected health information (PHI) may be used and/or disclosed for treatment,
payment, and health care operations purposes with your consent. To help clarify these
terms, here are some definitions.

 

• • PHI refers to information in your health record that could identify you.

 

• •Treatment, Payment and Health Care Operations

  •  Treatment is when your health care and other services related to your health care are provided or managed. An example of this is consultation with another healthcare provider, such as your family physician or another mental health professional.​

  • Payment is being reimbursed for your health care. Examples of payment are when your PHI is disclosed to your health insurance to obtain reimbursement for your health care or to determine eligibility or coverage

  • ​Health Care Operations are activities that relate to the performance and operation of this practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

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• Use applies only to activities within the office, clinic, practice group, etc. such as

sharing, employing, applying, utilizing, and examining information that identifies you.

 

• Disclosure applies to activities outside of the office, clinic, practice group, etc.,

such as sending, transferring, or providing access to information about you to other
parties.

II. Uses and Disclosures Requiring Authorization

 

• PHI may be used or disclosed for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An authorization is written permission above and beyond course that permits only specific disclosures. In those instances when asked for information for purposes outside of treatment, payment, and health care operations, authorization will be obtained from you before releasing this information. Authorization will also need to be obtained before releasing your psychotherapy notes.

 

• You may revoke all authorizations of PHI or psychotherapy notes at any time, provided 
  each revocation is in writing. You may not revoke an authorization to the extent that that authorization has been relied on or if the authorization was obtained as a condition of gaining insurance coverage and the law provides the insurer the right to contest this right under that policy. 

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III. Uses and Disclosures with Neither Consent or Authorization

 

PHI may be used or disclosed without your consent or authorization in the following

circumstances: 

 

• Child Abuse: If there is cause to believe that a child has been or may be abused, neglected, or sexually abused, a report of such must be made within 48 hours to your state's Department of Family and Protective Services, or appropriate Youth Commission, or to any local or state law enforcement agency.

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• Adult and Domestic Abuse: If there is cause to believe that any elderly or disabled 
  person is in a state of abuse, neglect, or exploitation, it must immediately be reported such to the Department of Family and Protective Services.

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• Health Oversight: If a complaint is filed against treatment staff with any of the applicable State licensing Boards they have the authority to subpoena confidential mental health information relevant to that complaint.

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• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and the information would not be released without written authorization from you or your personal or legally appointment representatives, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

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• Serious Threat to Health or Safety: If it is determined that there is a probability of imminent physical injury by you to yourself or other--, or there is a probability of immediate mental or emotional injury to you, relevant confidential mental health information may be disclosed to medical or law enforcement personnel.

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• Workers Compensation: If you file a worker's compensation claim, records may be disclosed relating to your diagnosis and treatment to your employer's insurance carrier.

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IV. Patient's Rights and Psychotherapist's Duties Patient's Rights:

Right to Request Restrictions-You have (he tight to request restrictions on certain
uses and disclosures of PHI about you. However, agreement to a restriction you request is
not required.

Right to Receive Confidential Communications by Alternative Means and
Alternative Locations - You have the right to request and receive confidential
communication of PHI by alternative means at alternative locations. For example, you
may not want a family member to know that you are being seen. Upon your request, bills
or other materials will be sent to another address.

Right to Inspect and Copy -You have the right to inspect and/or obtain a copy of
your PHI and psychotherapy notes in your mental health and billing record. Access to

your PHI may be denied under certain circumstances, but in some cases you may have this
decision reviewed. On your request, the details of the request and denial process will be
discussed with you.

Right to Amend - You have the right to request an amendment of PHI for as long
as the PHI is maintained in the record. On your request, the details of the amendment
process will be discussed with you.

Right to an Accounting - You generally have the right to receive an accounting of
disclosures of PHI for which you have neither provided consent nor authorization (as
described in Section III of this Notice). On your request, the details of this accounting
process will be discussed with you.

Right to Paper Copy - You have the right to obtain a paper copy of the notice upon
request, even if you have agreed to receive the notice electronically.

Psychotherapist's Duties:

 

• Treatment staff is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.

 

• Treatment staff reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, treatment staff is required to abide by the terms currently in effect.

If the policies and procedures are revised, you will be provided with a written copy.

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V. Questions and Complaints

If you have questions about this notice, disagree with a decision that is made about access
to your records or have other concerns about your privacy rights, you may contact Ian
Vassilaros, LPC to address them.

You may send a written complaint to the Secretary of the Office of Civil Rights of the
United States. U. S. Department of Health and Human Services, 200 Independence Ave,
SW. Room 509F. Washington. DC 20201. You may also contact the Office of Civil Rights'
Hotline at 1-800-368-1019.

You have specific rights under the Privacy Rule. Retaliation against you for exercising
your right to file a complaint will not be made.