Libratum Counseling, LLC 142 W. Market St., 2nd Floor
610.616.5890 West Chester, PA 19382
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Libratum Counseling, LLC provides outpatient mental health and behavioral health services. As individual therapists we have a legal responsibility under the laws of the United States and the state of Pennsylvania to keep your health information private. Part of our responsibility is to give you this notice about the privacy practices. Another part of our responsibility is to follow the practices in this notice. This form is effective January 1, 2019.
Uses and Disclosures for Treatment, Payment and Health Care Operations:
Libratum Counseling, LLC may use or disclose your protected health information (PHI) for treatment, payment and health care operations 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 we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another therapist
- Payment. We will use and disclose your PHI to obtain payment for services. Before you receive services, we may disclose PHI to your insurance company, health plan, county, or other third party payer to permit them to: make determinations of eligibility or coverage; review the medical necessity of your services; review your coverage; or review the appropriateness of care or the charges. I will also use your PHI for billing, claims management, collection activities, and data processing. For example, a bill may be sent to you or whoever pays for your services. The bill may include PHI that identifies you as well as your diagnosis and procedure codes used in the course of your treatment.
- Health Care Operations are activities that relate to the performance and operate of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as billing, audits, and administrative services, and case management and care coordination.
- “Use” applies only to the activities within my practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
- “Disclosure” applies to activities outside of my practice such as releasing, transferring, or providing access to information about you to other parties.
Uses and Disclosures Requiring Authorization:
Libratum Counseling, LLC may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained, An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information.
Libratum Counseling, LLC will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes that are made about our conversation during a private, group, joint, or family counseling session, which have been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. We do not necessarily keep psychotherapy notes on all patients or for all sessions.
You may revoke all such 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 (1) we have relied on that authorization, or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
Uses and Disclosure with Neither Consent nor Authorization:
We may use or disclose PHI without your consent or authorization in the following circumstances.
- Child abuse: If we have reasonable cause, on the basis of professional judgement, to suspect abuse or serious neglect of children with whom we come into contact in my professional capacity, we are required by law to report this to the Pennsylvania Department of Public Welfare.
- Adult and Domestic Abuse: If we have reasonable cause to believe that an older adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we may report such to the local agency with provides protective services.
- Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services provided to you or the records thereof, such information is privileged under state law, and we will not release the information without your written consent, 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 express a serious threat, or intent to kill or seriously injure an identified or readily identifiable person or group of people, and it is determined that you are likely to carry out the threat we must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of the threat or intent.
Your Rights Regarding Your PHI:
- Rights to Request Restriction: You have the right to request a limitation or a restriction on our use or disclosure of your PHI for treatment, payment or healthcare operations. You may also request that we limit the PHI I disclose to family members, friends or a personal representative who may be involved in your care. However, we are not required to agree to a restriction. If we agree to the requested restriction, we may note use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by making your request in writing, including (a) what PHI you want to limit; (b) whether you want me to limit my use, disclosure or both; and (c) to whom you want the limits to apply.
- Right to request Confidential Communication: You have the right to request that confidential communications from me be sent to you in a certain way or at an alternative location. For example, you can ask that we only contact you at your home or by mail. We will accommodate reasonable requests. We may also condition this accommodation by asking you for specific information. We will not request an explanation from you as to the basis for the request. Please make this request in writing specifying how or where you wish to be contacted.
- Right to Inspect and Copy: You have the right to inspect and obtain a copy of your PHI that is contained in my records. However, you may not inspect or copy the following records: psychotherapy notes; or information compiled in reasonable anticipation of, or us in, a civil, criminal, or administrative action or proceeding. In addition you may be denied access to your PHI if it was obtained from a person under a promise of confidentiality; or disclosure is likely to endanger the life and physical safety of you or another person. A decision to deny access may be reviewed. To inspect and copy PHI, submit your request in writing. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other related costs.
- Right to Amend: If you believe the PHI that we have collected about you is incorrect, you have certain rights. If you are receiving mental health services, you have the right to submit a written statement qualifying or rebutting information in our records that you believe is erroneous or misleading. This statement will accompany any disclosure of your records. You also have the right under the HIPPA Privacy Regulations to request an amendment of the PHI maintained in my records. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend PHI that: was not created by us (unless the person or entity that created the information is no longer available to make the amendment); the information is not part of the record kept by Libratum Counseling, LLC; the PHI is not subject to inspection or copying; or the record is accurate and complete. If we deny your request for amendment, you have the right to appeal the decision and file a statement of disagreement. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact Libratum Counseling, LLC if you have questions about submitting a written statement or to request an amendment of your records.
- Right to Receive an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we have made of PHI about you. We are not required to account for disclosures related to: treatment, payment, or my health care operations; authorizations signed by you; or disclosures to you, to family members or your personal representative involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after July 1, 2016.
- Right to a Paper Copy of this Notice: You have the right to receive a paper copy of this notice upon request.
Grievance Procedures: Right to File a Complaint
If you are not pleased with your care or feel your PHI was not kept confidential you may officially file a grievance with us. Under the DCS grievance procedure, we will work with you to address your questions, concerns and complaints. The HIPPA Privacy Regulations also entitle you to file a complaint with the U.S. Secretary of Health and Human Services. To file a complaint or learn more about the grievance process, you may contact Libratum Counseling, LLC at 610.616.5890, by mail at 142 W. Market Street, 2nd Floor, West Chester, PA 19382 or email at email@example.com. There will not be any retaliation against you for filing a complaint.