707 N Courthouse Rd. N Chesterfield, VA 23236 804-924-2236
THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. THIS DOCUMENT ALSO COVERS INFORMED CONSENT. *PLEASE REVIEW CAREFULLY.*
I. Confidentiality
MySpectrum Counseling & Coaching is legally required to protect the privacy of your Protected Health Information (PHI), which includes information that can be used to identify you that is created or received by MySpectrum Counseling & Coaching or their therapist about your past, present or future health or condition, the provision of healthcare to you, or the payment for this health care. MySpectrum Counseling & Coaching must provide to you with this Notice about our privacy practices, and such Notice must explain how, when, and why MySpectrum Counseling & Coaching will “use” and “disclose” your PHI. A “use” of PHI occurs when MySpectrum Counseling & Coaching shares, examines, utilizes, applies, or analyzes such information within our practice. PHI is “disclosed” when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of our practice. With some exceptions, MySpectrum Counseling & Coaching may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. And, MySpectrum Counseling & Coaching is legally required to follow the privacy practices described in this notice.
II. Operational and Billing Use
MySpectrum Counseling & Coaching can use and disclose your PHI to bill and collect payment for the treatment and services provided to you. PHI may also be used or disclosed to business associates, such as billing companies, claims processing companies, and others that process claims on behalf of MySpectrum Counseling & Coaching. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Out of Pocket Payments: If you paid out of pocket (in other words, you have requested that MySpectrum Counseling & Coaching not bill your health plan) in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and MySpectrum Counseling & Coaching will honor that. This request must be received in writing with specific details as to which service this applies.
III. “Limits of Confidentiality” & INFORMED CONSENT TO TREATMENT
Possible Uses and Disclosures of Mental Health Records without Consent or Authorization
There are some important exceptions to this rule of confidentiality - some exceptions are due to the policies of MySpectrum Counseling & Coaching and some are required by law. If you wish to receive mental health services from MySpectrum Counseling & Coaching you must sign the attached form indicating your accept and understand these policies about confidentiality and its limits. Please feel free to discuss any questions or concerns with your therapist.
MySpectrum Counseling & Coaching 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 by law:
- Emergency - If you are involved in a life-threatening emergency and MySpectrum Counseling & Coaching cannot ask your permission, MySpectrum Counseling & Coaching will share information if MySpectrum Counseling & Coaching believes you would have wanted us to do so, or if MySpectrum Coaching & Counseling believes it will be helpful to you.
- Child Abuse Reporting: If MySpectrum Counseling & Coaching has reason to suspect that a child is abused or neglected, MySpectrum Counseling & Coaching is required by law to report the matter immediately to the Virginia Department of Social Services.
- Adult Abuse Reporting: If MySpectrum Counseling & Coaching has reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, MySpectrum Counseling & Coaching is required by law to immediately make a report and provide relevant information to the Virginia Department of Welfare or Social Services.
- Health Oversight: Virginia law requires that Licensed Clinical Social Workers and Counselors report misconduct by a health care provider of their own profession. By policy, MySpectrum Counseling & Coaching also reserves the right to report misconduct by health care providers of other professions. By law, if you describe unprofessional conduct by another mental health provider or any profession, MySpectrum Counseling & Coaching is required to explain to you how to make such a report. If you are yourself a health care provider, MySpectrum Counseling & Coaching is required by law to report to your licensing board that you are in treatment with MySpectrum Counseling & Coaching if we believe your condition places the public at risk. Virginia Licensing Boards have the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.
- Court Proceedings: If you are involved in a court proceeding and a request is made for information regarding your diagnosis and treatment and the records thereof, such information is privileged under the state law and MySpectrum Counseling & Coaching will not release information unless you provide written authorization or a judge issues a court order. If MySpectrum Counseling & Coaching receives 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, MySpectrum Counseling & Coaching is required to place said records in a sealed envelope and provide to the Clerk of the Court. In Virginia civil court cases, therapy information is not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be “necessary for the proper administration of justice”. In criminal cases, Virginia has no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if MySpectrum Counseling & Coaching does 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 Virginia law, if MySpectrum Counseling & Coaching is engaged in 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 MySpectrum Counseling & Coaching believes you have the intent and ability to carry out that threat immediately or imminently, MySpectrum Counseling & Coaching is legally required to take steps to protect third parties or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. MySpectrum Counseling & Coaching policy also states that 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, MySpectrum Counseling & Coaching can be required to provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, or a law enforcement officer, whether you are a minor or an adult.
- Workers Compensation; If you file a worker’s compensation claim, MySpectrum Counseling & Coaching is required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
- Records of Minors: Virginia has a number of laws that limit the confidentiality of the records of minors. For example, parents regardless of custody, may not be denied access to their child’s records; and CSB evaluators in civil commitment cases have legal access to therapy records without notification or consent of parents or child. Other circumstances may also apply, and MySpectrum Counseling & Coaching will discuss these in detail if we provide services to minors.
Other uses and disclosures of information not covered by this notice or the laws that apply to MySpectrum Counseling & Coaching will be made only with your written permission.
IV. Patient’s Right and Provider 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 MySpectrum Counseling & Coaching discloses about you to someone who is involved in your care or the payment of your care. If you ask MySpectrum Counseling & Coaching to disclose information to another party, your may request that MySpectrum Counseling & Coaching limit the information that is disclosed. However, MySpectrum Counseling & Coaching is not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell MySpectrum Counseling & Coaching 1) what information you want to limit, 2) whether you want to limit MySpectrum Counseling & Coaching’s use, disclosure or both; and 3) to whom the limits 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 that you are being seen at MySpectrum Counseling & Coaching. Upon your request, MySpectrum Coaching & Counseling will send your bills to another address. You may also request that MySpectrum Counseling & Coaching contact you only at work, or that MySpectrum Counseling & Coaching do not leave a voicemail message 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, MySpectrum Counseling & Coaching 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, MySpectrum Counseling & Coaching may charge a fee for the costs of copying and mailing. MySpectrum Counseling & Coaching may deny your request to inspect and copy in some circumstances. MySpectrum Counseling & Coaching may refuse to provide you access to certain psychotherapy notes or information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative proceeding.
- Right to Amend: If you feel that protected health information MySpectrum Counseling & Coaching has about you is incorrect or incomplete, you may ask your therapist to amend the information. To request an amendment, your request must be made in writing, and submitted to MySpectrum Counseling & Coaching. In addition, you must provide a reason that supports your request. MySpectrum Counseling & Coaching may deny your request if you ask for information to be amended that 1) was not created by MySpectrum Counseling & Coaching however MySpectrum Counseling & Coaching will add the request to the record; 2) is not part of the medical information kept by MySpectrum Counseling & Coaching; 3) is not part of the information which your would be permitted to inspect and copy; and 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 MySpectrum Counseling & Coaching staff to give you a copy of this notice at any time. Changes to this notice: MySpectrum Counseling & Coaching reserves the right to change its policies and/or change this notice, and to make the changed notice effective for medical information already received by MySpectrum Counseling & Coaching about you as well as any information MySpectrum Counseling & Coaching receives in the future. The notice will contain an effective date. A new copy will be given to you or posted in the reception area. MySpectrum Counseling & Coaching will have copies of the current notice available upon request. You may also request to receive this notice by email.
- Right to Get Notice of a Breach: You have the right to be notified upon a breach of any of your unsecured PHI.
Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request to MySpectrum Counseling & Coaching in writing. You may also send a written complaint to the Virginia or U.S. Department of Health and Human Services at:
Virginia Secretary of Health & Human Services 202 North 9th Street, Suite 622 Richmond, Virginia 23219 804-786-7765
Secretary of Health & Human Services Hubert Humphrey Building 2000 Independence Avenue, S.W. Washington D.C. 20201 20-690-70000
707 N Courthouse Rd N Chesterfield, VA 23236 804-924-2236