This notice contains information about the Health Insurance Portability and Accountability Act (HIPPA), a federal law providing privacy protections and patient rights regarding the use and disclosure of a patient’s Protected Health Information (PHI) for the purpose of treatment, payment and healthcare. 

PLEASE REVIEW IT CAREFULLY.

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The HIPPA law allows for the use or discloser of PHI for:
 

• Treatment: Providing, coordinating, or managing a patient's health care and other services related to the patient’s health care, such as a patient's therapist consulting with another healthcare provider.

• Payment: Obtaining reimbursement for a patient's healthcare. For example, disclosing a patient's PHI to a patient's health insurer to assist the patient in obtaining reimbursement for healthcare costs, or to determine a patient's insurance eligibility or coverage.

• Health Care Operations: Activities that relate to the performance and operation, such as quality assessment and improvement activities, business-related matters such as audits and administrative services, and clinical peer review.

    
Uses and Disclosures Requiring Authorization
 

Beyond the general consent that permits only specific disclosures, a patient may choose to sign a Release of Information authorizing a specific disclosure. Patients may revoke an authorization of PHI at any time, provided each revocation is in writing. Patients may not revoke an authorization when PHI was already released based on an authorization; nor if the authorization was obtained as a condition of obtaining insurance coverage, and law provides the insurer the right to contest the claim under the policy.
 

Uses and Disclosures without your Consent or Authorization
 

• Child Abuse: I am required to report PHI to the appropriate authorities when I have reasonable grounds to believe that a minor is or has been the victim of neglect, physical and/or sexual abuse.

•  Adult and Domestic Abuse: If I have the responsibility for the care of an incapacitated or  vulnerable adult, I am required to disclose PHI when I have a reasonable basis to believe that abuse or neglect of the adult has occurred or that exploitation of the adult's property has occurred.

•  Health Oversight Activities: If the Arizona Board of Psychological Examiners is conducting an investigation, then I am required to disclose PHI upon receipt of a subpoena from the Board. Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services I provided you and/or the records thereof, such information is privileged under state law, and I will not release information without the written authorization from you or your legally appointed representative or a court order. The 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. 

• Serious Threat to Health or Safety: If you communicate to me an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim(s) and I believe you have the intent and ability to carry out such a threat, I have a duty to take reasonable precautions to prevent the harm from occurring, including disclosing information to the potential victim and the police and in order to initiate hospitalization procedures. 
  If I believe there is an imminent risk that you will inflict serious harm on yourself, I may disclose information in order to protect you.

• Worker’s Compensation: I may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law,  that provide benefits for work-related injuries or illness without regard to fault.

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Patient’s Rights
 

 

• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not required to agree to a restriction you request. 

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations:    
  You have the right to request and receive confidential communications of PHI by alternative means  and at alternative locations. (For example, you may not want a family member to know that you are  seeing me, on your request, I will send your bills to another address.)  

• Right to Inspect and Copy: 

• You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. 

• Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is  maintained in the record. However, psychologists may deny the request if they believe the record is accurate.

• Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI. Some exceptions do apply.

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

Psychologist’s Duties 
 

Psychologists are required by law to maintain the privacy of PHI and to provide you with a notice of  the psychologist’s legal duties and privacy practices with respect to PHI.

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Dr. Leiphart reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, she is required to abide by the terms currently in effect. If policies and procedures are revised, you will informed and provided with written documentation during your session or by mail.