Notice of Privacy Practices
Release of Information
Notice of Privacy Practices
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.
As required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA), this Notice of Privacy Practices describes how I may use and disclose your Protected Health Information (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI. PHI is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to revise or amend this Notice of Privacy Practices. The new notice will be effective for all PHI that I maintain at that time or in the future. Upon your request, I will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing my website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
My practice is dedicated to maintaining the privacy of your PHI. I am required by law to maintain the confidentiality of health information that identifies you. I am also required by law to provide you a copy of this Notice of Privacy Practices.
1. Uses and Disclosures of PHI:
Your PHI may be used and disclosed by, Matthew Grant, Psy.D., HSPP doing business as NorthStar Psychological + Consultation Services, LLC for the purpose of providing health care services to you. Your PHI may also be used and disclosed to pay your health care bills and to support the operation of NorthStar Psychological + Consultation Services, LLC. It’s important to understand, that when PHI is disclosed or used, I will share the minimum amount of information necessary to conduct the activity.
Following are examples of the types of uses and disclosures of your PHI that NorthStar Psychological + Consultation Services, LLC is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by my office.
Treatment: I will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider such as your physician or psychiatrist. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your PHI will be used and disclosed, as needed, to bill and obtain payment for your health care services provided by me. For example, I may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs such as family members or insurance companies to determine eligibility or coverage. However, should you elect to pay for services out of pocket in full, you have the right to restrict certain disclosures of your PHI to health plans/insurance companies.
Health Care Operations: I may use or disclose, as needed, your PHI in order to support the business activities of NorthStar Psychological + Consultation Services, LLC. These activities include, but are not limited to, quality assessment activities, administrative services, case management, care coordination, and conducting cost management or arranging for other business activities.
Business Associates: I will share your PHI with third party “business associates” that perform various activities (e.g, billing or transcription services) for my practice. Whenever an arrangement between my office and a business associate involves the use or disclosure of your PHI, I will have a written contract that contains terms that will protect the privacy of your PHI. I will monitor this contract to ensure that the business associate is complying.
Breach Notification: In the event that I discover that your PHI has been breached, you will be informed along with U.S. Department of Health and Human Services.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object
I may use or disclose your PHI in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:
Required By Law: I may use or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
Public Health: I may disclose your PHI for public health activities and purposes to a public health authority that is authorized by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.
Communicable Diseases: I may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight: I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, licensure and disciplinary actions, civil, administrative, and criminal procedures. For example, if the Indiana Attorney General’s Office is conducting an investigation into my practice, then I am required to disclose PHI upon receipt of a subpoena.
Abuse or Neglect: I may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, I may disclose your PHI if I believe that you have been a victim of abuse, neglect or domestic violence to the agency authorized to receive such information consistent with the requirements of applicable federal and state laws.
Lawsuits and Similar Proceedings: If you are involved in a lawsuit or similar proceeding, and a request is made to obtain information about the professional services you have received from NorthStar Psychological + Consultation Services, LLC, I may disclose your PHI if subpoenaed or court ordered. Although your PHI is privileged under state law, I will not release information without the written authorization from you or your appointed representative. This privilege does not apply when you are being evaluated for a third party or when the evaluation is court ordered. You will be informed in advance if this is the case. Generally, I will require that the party whom requests your records provide a records-release, signed by you, within the last 3 months.
Law Enforcement: I may disclose your PHI if asked to do so by law enforcement officials, so long as applicable legal requirements are met. These law enforcement purposes include (1) in response to a warrant, summons, court order, subpoena or other legal process, (2) to identify and locate a suspect, material witness, fugitive, or missing person, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of my practice, and (6) in an emergency to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).
Coroners, Funeral Directors, and Organ Donation: I may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. I may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. PHI may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research: I may disclose your PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
Serious Threat to Health or Safety: Consistent with applicable federal and state laws, I may disclose your PHI, if you communicate to me an actual threat of violence with an intention to cause serious injury or death against a reasonably identifiable victim or victims. In addition, if you present evidence, conduct or make statements indicating an imminent danger that you will use physical violence or other means to cause serious injury or death to others, I will take the appropriate steps to prevent that harm from occurring. If I have reason to believe that you present an imminent, serious risk of physical harm or death to yourself, I will need to disclose information in order to protect you. In both cases, I will only disclose what I feel is the minimum amount of information necessary.
Military Activity and National Security: When the appropriate conditions apply, I may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. I may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers’ Compensation: I may disclose your PHI as authorized to comply with workers’ compensation laws and other similar legally-established programs.
Inmates: If you are an inmate, I may use or disclose your PHI to correctional institutions or law enforcement officials. This would be necessary in order that the institution can provide health care services to you, for the safety and security of the institution, and to protect your health and safety or the health and safety of other individuals.
Uses and Disclosures of PHI Based upon Your Written Authorization
Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, I will no longer use or disclose your PHI for the reasons covered by your written authorization. Please understand that I am unable to take back any disclosures already made with your authorization.
Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object
I may use and disclose your PHI in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the use or disclosure of the PHI, then I may, using professional judgment, determine whether the disclosure is in your best interest.
Others Involved in Your Health Care or Payment for your Care: Unless you object, I may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, I may disclose such information as necessary if I determine that it is in your best interest based on my professional judgment. I may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.
2. Your Rights
Following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights.
You have the right to inspect and copy your PHI: This means you may inspect and obtain a copy of PHI about you for so long as I maintain the PHI. You may obtain your mental health record that contains mental health and billing records and any other records that I use for making decisions about you. As permitted by federal or state law, I may charge you a reasonable copy fee (up to .10¢ per page) for a copy of your records.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact me if you have questions about access to your mental health record.
You have the right to request a restriction of your PHI: This means you may ask me not to use or disclose any part of your PHI for the purposes of treatment, payment or health care operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
I am not required to agree to a restriction that you may request. If I agree to the requested restriction, I may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with me. You may request a restriction by writing a letter detailing what information you would like to be restricted. Please date and sign the letter.
You have the right to request to receive confidential communications from me by alternative means or at an alternative location: I will accommodate reasonable requests. I may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. I will not request an explanation from you as to the basis for the request. Please make this request in writing.
You may have the right to have your provider amend your PHI: This means you may request an amendment of PHI about you in a designated record set for so long as I maintain this information. In certain cases, I may deny your request for an amendment. If I deny your request, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact me if you have questions about amending your mental health record.
You have the right to receive an accounting of certain disclosures I have made, if any, of your PHI: This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures I may have made on your behalf, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after this date. The right to receive this information is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from me, upon request, even if you have agreed to accept this notice electronically.
Should you feel that your privacy rights have been violated, I would prefer that you address your concern with me. However, should you feel uncomfortable doing so, you may make your complaint to the U.S. Department of Health and Human Services, the Office of Civil Rights by calling 1-800-368-1019, or by visiting their website at www.hhs.gov/ocr/privacy/hippa/complaint/index.html on details of "How To File a Complaint."
This notice will go into effect on August 1, 2011
Notice of Privacy Practices and Patient Rights
I have received or reviewed the notice of privacy practices for NorthStar Psychological + Consultation Services LLC, and understand the situations in which this practice may need to utilize or release my mental health records. I also understand that I agreed to the use of those records when I initially applied for care at this office on my first visit, whenever that may have occurred.
I have received or reviewed the statement of patient rights for NorthStar Psychological + Consultation Services, LLC and was offered an oral explanation of these rights.
Patient Name (serves as signature)
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429 E. Vermont Street
Indianapolis, IN 46202
317-572-7847 (ST4R) Call/Text
Mon - Thurs: 9:00 a.m. - 8:00 p.m. Closed all other days