Privacy Policy

Notice of Privacy Practices

THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Confidentiality

As a rule, we will disclose no information about you or that you are a patient without your written consent. Our formal Mental Health Record describes the services provided to you. It contains the dates of sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. Healthcare providers are legally allowed to use or disclose records or information for treatment, payment, and healthcare operations purposes. However, we do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing a general consent form) or through your written authorization when the need for disclosure arises. You may revoke your permission, in writing, at any time.

II. “Limits of Confidentiality”

Possible Uses and Disclosures of Mental Health Records without Consent or Authorization

There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by the clinician, and some required by law. If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits. We will discuss these issues now, but you may reopen the conversation anytime.

We may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy or because legally required:

· Emergency: If you are involved in a life-threatening emergency and we cannot ask your permission, we will share information if we believe you would have wanted us to do so or if we believe it is necessary for continuity of care (i.e., if you suffer a medical emergency during a session).

· Child Abuse Reporting: If I suspect that a child is abused or neglected, we are required by Wisconsin law to report the matter immediately to the Department of Health and Human Services in the county of incident and/or directly to Law Enforcement.

· Adult Abuse Reporting: If we have reason to suspect that an elderly or incapacitated adult is abused, neglected, or exploited, we are required by Wisconsin law to immediately make a report and provide relevant information to the Department of Health and Human Services in the county of incident, and/or directly to Law Enforcement.

· Health Oversight: Wisconsin law requires that licensed professional counselors report misconduct by another provider of their own profession. By policy, we also reserve the right to report misconduct by healthcare providers of other professions. By law, if you describe unprofessional conduct by another mental health provider of any profession, we must explain how to make such a report. If you are a health care provider, I am legally required to report to your licensing board that you are in treatment with me if I believe your condition places the public at risk. When necessary, the Wisconsin Department of Safety and Professional Services can subpoena relevant records in investigating a complaint of provider incompetence or misconduct.

· Court Proceedings: If you are involved in a court preceding, and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and we will not release information unless you provide written authorization, or a judge issues a court order. If we receive a subpoena for records or testimony, we will notify you so you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, we must place said records in a sealed envelope and provide them to the Clerk of Court. Protections of privilege may not apply if I do an evaluation 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: Under Wisconsin law, if we are engaged in our professional duties and you communicate to us a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and we believe you have the intent and ability to carry out that threat immediately or imminently, we are legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s) or the parent or guardian of the potential victim(s) if under 18, 2) notifying law enforcement, or 3) seeking your hospitalization. By our own policy, we may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, we can be required to provide your records to the magistrate, your attorney or guardian ad litem, or a law enforcement officer, whether you are a minor or an adult.

· Workers Compensation: If you file a worker’s compensation claim, we are required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.

Other uses and disclosures of information not covered by this notice or by the laws that apply to us will be made only with your written permission.

III. Patient’s Rights and Provider’s Duties:

· Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care. If you ask us to disclose information to another party, you may request that we limit the information disclosed. However, we are not required to agree to a restriction you request. To request restrictions, you must make your request in writing and tell us: 1) what information you want to limit; 2) whether you want to limit our use, disclosure, or both; and 3) to whom you want the limits to apply.

· 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 you are seeing a therapist. Upon your request, we will send your bills to another address. You may also request that we contact you only at work or that we do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.

· Right to an Accounting of Disclosures – 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 written request, we will discuss with you the details of the accounting process.

 · Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, we may charge a fee for the costs of copying and mailing. We may deny your request to inspect and copy in some circumstances. We may refuse to provide you with access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative proceeding.

· Right to Amend – If you feel that the protected health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, your request must be made in writing and submitted to us. In addition, you must provide a reason that supports your request. We may deny your request if you ask us to amend information that: 1) was not created by your therapist; we will add your request to the information record; 2) is not part of the medical information kept by us; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.

· Right to a copy of this notice – You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice anytime. Changes to this notice: We reserve the right to change our policies and/or to change this notice and to make the notice effective for medical information we already have about you and any information we receive in the future. The notice will contain the effective date. A new copy will be given to you or posted in the waiting room. We will have copies of the current notice available on request.

Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.