ACT Notice of Privacy Practices

Following is Notice of ACT’s Policies and Practices

to Protect the Privacy of Your Health Information

 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.

 I.  Uses and Disclosures for Treatment, Payment, and Health Care Operations 

ACT Medical Group, PA, and its representatives (herein referred to as “ACT”) may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your consent.

·         “PHI” refers to information in your health record that could identify you.

·         “Treatment, Payment and Health Care Operations”

– Treatment is when ACT provides, coordinates or manages your health care and other services related to your health care. Example: consultation with another health care provider, such as your family physician or another psychologist.

- Payment is when ACT obtains reimbursement for your healthcare.  Examples: disclosure of PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

- Health Care Operations are activities that relate to the performance and operation of ACT’s practice.  Examples:  quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

·         “Use” applies only to activities within my practice group such as billing, medical records management, and care coordination.

·         “Disclosure” applies to activities outside of my practice group, such as releasing or providing access to information about you to other parties.

 II.  Uses and Disclosures Requiring Authorization

ACT may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your written, specific authorization is obtained. “Psychotherapy notes” are those notes involving conversations during counseling sessions that are designated by the psychologist to be kept separate from other PHI.  These notes are given a greater degree of protection than PHI and will require specific, written authorization for their release.

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) ACT has taken action in reliance on the 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.

 III.  Uses and Disclosures with Neither Consent nor Authorization

ACT may use or disclose PHI without your consent or authorization in the following circumstances:

§         Child Abuse: If you provide information that leads an ACT representative to suspect child abuse, neglect, or death due to maltreatment, ACT must report such information to the Department of Social Services (DSS) and release information from your records relevant to a child protective services investigation upon request by the DSS.

§         Adult and Domestic Abuse: If information you give an ACT representative suggests reasonable cause to believe that a disabled adult is in need of protective services, ACT must report this to the DSS and provide information from your records relevant to a protective services investigation if requested by the DSS. 

§         Health Oversight: The North Carolina Psychology and Medical Boards have the power, when necessary, to subpoena relevant records should an ACT clinician be the focus of an inquiry.

·         Judicial or Administrative Proceedings: If you are involved in a court proceeding, and a request is made for information about the professional services that ACT has provided you and/or the records thereof, such information is privileged under state law, and ACT must not release this information without your written authorization, or a court order.  This 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: ACT may disclose your confidential information to protect you or others from a serious threat of harm by you.

·         Worker’s Compensation: If you file a workers’ compensation claim, ACT is required by law to provide your mental health information relevant to the claim to your employer and the North Carolina Industrial Commission. 

 IV.  Patient's Rights and ACT's Duties

Patient’s Rights:

• Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of your PHI.  ACT is 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. Example: you may request that bills be sent to a location other than your home address.
• Right to Inspect and Copy – You have the right to inspect and/or obtain a copy of PHI in ACT’s mental health and billing for as long as the PHI is maintained in the record. ACT may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, ACT will discuss with you the details of the request and denial process.
• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. ACT may deny your request.  Upon your request, ACT will discuss with you the details of the amendment process.
• Right to an Accounting – You 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). 
• 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

 ACT’s Duties:

·         ACT is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

·         ACT reserves the right to change the privacy policies and practices described in this notice. Unless ACT notifies you of such changes, however, ACT is required to abide by the terms currently in effect.

·         If ACT revises privacy policies and procedures, ACT will notify you by mail.

V.  Complaints

If you are concerned that ACT has violated your privacy rights, or you disagree with a decision ACT has made about access to your records, you may contact the ACT Privacy Officer at 888-311-1254.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  ACT can provide you with the appropriate address upon request.

VI.  Effective Date

This notice will go into effect on April 14, 2003.