KU Psychological Clinic

 Revised 3/12/2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

Each time you visit The KU Psychological Clinic, a record of your visit is made. This record typically contains information regarding symptoms, observations, assessments (including test results and diagnoses), plans for future treatment, and billing information. This Notice of Privacy Practices (NPP) describes how we may use and disclose your information. It also describes your rights and our responsibilities regarding the use and disclosure of your information. This NPP applies to all records generated or maintained by The KU Psychological Clinic.

OUR RESPONSIBILITIES REGARDING YOUR HEALTH INFORMATION:

We are required by law to protect the privacy of your health information. We also are providing you with this NPP, we agree to abide by the terms of the NPP currently in effect, and we will notify you if we are unable to agree to any restrictions you request on the use or disclosure of your information.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION THAT REQUIRE YOUR WRITTEN PERMISSION:

Each of the uses and disclosures listed immediately below requires your written permission. Whenever you provide us with permission to use or disclose information, you may withdraw that permission at any time.

a. Treatment & Supervision. We will ask for your written permission to use your health information within the KU Psychological Clinic in order to provide and coordinate your services. For example, your health information will be used by those clinic staff members who are directly involved in your treatment, including your therapist and the licensed supervisor.

b. Payment. We will ask for your written permission to use and disclose information regarding the services provided to you in order to bill and collect payment from you. For example, if your account becomes delinquent, we may need to report your account information to the KU collection service for them to pursue payment.

c. Training Functions. The KU Psychological Clinic is a training facility. We will ask for your written permission to use and disclose information about you to a small group of doctoral students in training (i.e., a "supervision team") for educational purposes.

d. Other Uses and Disclosures. In addition to the above, we will require your written permission for us to use or disclose your medical information:

• If the Clinic refers you to another health care provider (such as a physician). We will ask you to authorize our sending your health information to them so that they have the information needed to diagnose or treat you.

• If you ask the Clinic to disclose your health information to anyone, including other health care or educational professionals.

• To friends or family members who are involved in your care. If your written permission is not obtained and you are not present and able to agree or object, such communications shall be made only by authorized healthcare providers when, in their professional judgment, such disclosure is in your best interest.

• To members of our staff who are involved in quality improvement who want to use your information to assess the care and outcomes in your case and others like it. For example, we may analyze information about many clients in order to evaluate the need for new services, resources or treatments and to see where we can make improvements.

• Any uses or disclosures of your medical information that are not specifically covered by this NPP or by the laws that apply to us will be made only with your written permission.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION THAT DO NOT REQUIRE YOUR WRITTEN PERMISSION:

In certain situations we may disclose your health information without your written permission. For example, it may be necessary to disclose some information about you in an emergency. We also may use or disclose your health information without your written permission:

a. When we are Required to by Law. We may be required to disclose information to the following types of entities, including but not limited to:

• Workers Compensation Agents

• Military Command, National Security or Intelligence Authorities

• Health Oversight Agencies

• Public Welfare agencies charged with the investigation or prevention of abuse or neglect of children or dependent elders

b. For Law Enforcement or Legal Proceedings. We may disclose health information for law enforcement purposes in response to a valid court order or other legal process.

c. For Research. We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research and has taken steps to ensure the privacy of your personal health information.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION:

The Right To Inspect & Copy. You have the right to inspect and have copies of the health care information we use to make decisions about your care. Usually, this includes health and billing records, but does not include some records such as psychotherapy notes. Your request to inspect and copy must be submitted in writing. We may charge a fee for the costs of copying. Ask the Clinic receptionist for the "Right to Inspect & Copy" request form.

The Right to Amend. If you believe the information we have about you is incorrect or incomplete, you may ask us to change the information. Any request to change the information in your record must be submitted in writing. You will be asked to provide a reason for the request. Ask the Clinic receptionist for the "Amendment of Information Request Form."

The Right to an Accounting of Disclosures. You have the right to receive a list of the disclosures the Clinic has made of your health information. This list will not include all disclosures made. For example, this list will not include disclosures made prior to April 14, 2003, or disclosures that you have specifically authorized in writing. Request for this list must be submitted in writing. Ask the Clinic receptionist for the "Accounting of Disclosures Request Form. "

The Right to Request Restrictions. You have the right to request a restriction on the information we use or disclose about you for treatment, payment or health care operations. We are not, however, required to agree to all such requests. If we do agree, we will comply unless the information is needed to provide you with emergency treatment. Requests for restrictions must be submitted in writing. Ask the Clinic receptionist for the "Restrictions On Use and Disclosure of Information Request Form."

The Right to Request Confidential Communications. You have the right to ask the Clinic to communicate with you in a certain way or at certain locations. We will accommodate all reasonable requests. Unless we are otherwise instructed, phone calls to you from the Clinic for purposes of scheduling or canceling sessions and mailings to you for purposes of billing will be directed to the home phone number (s) and home address that you provide us. Requests for alternative modes or locations of communication must be submitted in writing. Ask the Clinic Receptionist for the "Confidential Communications Request Form."

The Right To A Paper Copy of This Notice. You have the right to receive a paper copy of this notice, and you may ask us for a copy at any time. You also may obtain a copy at the Clinic website: http://www.psych.ku.edu/psyclinic/

All of the forms mentioned above are available from the KU Psychological Clinic at (785) 864-4121.

COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint with us by contacting the Director of the Clinic at (785) 864-9853 or by contacting the University's HIPAA Privacy Officer, Lawrence Campus, at (785) 864-9528. You also may contact the Secretary of the US Department of Health and Human Services. There will be no retaliation for filing a complaint.

CHANGES TO THIS NOTICE

We reserve the right to change this NPP. Any revised NPP will be effective for information we already have about you as well as for information we receive in the future. Should our practices change, we will post a revised NPP on the KU Psychological Clinic website and in the Clinic office where you receive services. Paper copies will be available upon request.

QUESTIONS AND INFORMATION

If you have any questions about this notice, you may contact: the Clinic Director, Sarah B. Kirk, Ph.D. at (785) 864-9853.