AGAPE clinicians, Case managers and their support staff may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

• “PHI” refers to information in your health record that could identify you.
  
  
• “Clinician” refers to any mental health professional who provides clinical services. At AGAPE this includes both psychiatry staff and psychotherapists/counselors.
  
  
• “Treatment, Payment and Health Care Operations”
  • Treatment is when your AGAPE clinician provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when the clinician consults with another health care provider, such as your family physician or another mental health professional.
    
    
  • Payment is when AGAPE obtains reimbursement for your healthcare.  An example of payment is when your clinician discloses your 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 the AGAPE office practices.  Examples of health care operations are 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 AGAPE such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
    
    
  • “Disclosure” applies to activities outside of AGAPE such as releasing, transferring, or providing access to information about you to other parties.
    
    
  • “Consent” means that you give prior permission. You give AGAPE consent to handle your PHI as outlined in this Notice when you sign the Patient Acknowledgement form

Your AGAPE clinician or case manager 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 your clinician is asked for information for purposes outside of treatment, payment and health care operations, the clinician will obtain an authorization from you before releasing this information.  The clinician will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes the clinician has made about conversations with you 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.

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) the clinician has 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.

Your AGAPE clinician or case manager may use or disclose PHI without your consent or authorization in the following circumstances:

• Child abuse: If the clinician or case manager has knowledge of any child who is suffering from or has sustained any wound, injury, or disability, or physical or mental condition of such a nature as to reasonably indicate that it has been caused by brutality, abuse, or neglect, the clinician or case manager is required by law to report such harm immediately to Tennessee Child Protective Services or to the judge having juvenile jurisdiction, or to the office of the sheriff or the chief law enforcement official of the municipality where the child resides. Also, if the clinician or case manager has reasonable cause to suspect that a child has been sexually abused, the clinician or case manager must report such information, regardless of whether the child has sustained any injury.
  
  
• Adult and domestic abuse: If the clinician or case manager has reasonable cause to suspect that an adult who is vulnerable physically, mentally, or emotionally has suffered abuse, neglect, or exploitation, the clinician or case manager is required by law to report such information to the Tennessee Department of Human Services.
  
  
• Health oversight: If a complaint is filed against the clinician with the Tennessee Board of Examiners in Psychology (or other appropriate state Board of Examiners), the Board has the authority to subpoena confidential mental health information from me relevant to that complaint.
  
  
• Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that an AGAPE clinician or case manager has provided you and/or the records thereof, such information is privileged under state law, and the clinician 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. The AGAPE clinician or case manager must inform you in advance if this is the case.
  
  
• Serious threat to health or safety: If you communicate to your clinician or case manager an actual threat of bodily harm against a clearly identified victim, and the clinician or case manager has determined or reasonably should have determined that you have the apparent ability to commit such an act and are likely to carry out the threat unless prevented from doing so, the clinician or case manager is required to take reasonable care to predict, warn of, or take precautions to protect the identified victim from your violent behavior.
  
  
• Workers' compensation: If you file a worker's compensation claim, and the clinician is seeing you for treatment relevant to that claim, the clinician must, upon request, furnish to your employer or insurer, and to you, a complete report as to the claimed injury, the effect upon you, the prescribed treatment, and estimate of duration of hospitalization, if any, and a statement of charges.

Patient’s Rights:

• Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of PHI about you. However, the AGAPE clinician is not required to agree to a restriction that 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. (For example, you may not want a family member to know that you are seeing a clinician. Upon your request, your bills will be sent to another address.) 
  
  
• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in AGAPE’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, the AGAPE clinician will discuss with you the details of the request 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. The clinician may deny your request. On your request, the clinician will discuss with you the details of the amendment process.
  
  
• Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, the clinician will discuss with you the details of the accounting process. 

 

Clinician’s Duties:

 

• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from AGAPE upon request, even if you have agreed to receive the notice electronically.
  
  
• AGAPE is required by law to maintain the privacy of PHI and to provide you with a notice of its legal duties and privacy practices with respect to PHI.
  
  
• AGAPE reserves the right to change the privacy policies and practices described in this notice. Unless AGAPE notifies you of such changes, however, AGAPE is required to abide by the terms currently in effect.
  
  
• If AGAPE revises its policies and procedures, AGAPE will notify you by mail, phone, fax, or e-mail.

If you have questions about this notice, disagree with a decision an AGAPE clinician or case manager makes about access to your records, or have other concerns about your privacy rights, you may contact the AGAPE Privacy Officer at 615-781-3000.

If you believe that your privacy rights have been violated and wish to file a complaint with the AGAPE office, you may send your written complaint to Privacy Officer, AGAPE, 4555 Trousdale Drive, Nashville, TN 37204. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. AGAPE’s Privacy Officer can provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule. AGAPE will not retaliate against you for exercising your right to file a complaint.

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

AGAPE reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI maintained by AGAPE. AGAPE will notify you by mail, phone, fax, or e-mail of the revision of notice and make the revised notice available any of its offices. If needed, AGAPE will also provide a revised notice by mail, e-mail, or fax. Additionally, the notice will be made available on AGAPE’s website (agapenashville.org).

Your signature below indicates that you have received AGAPE’s “Notice of Clinicians’ Policies and Practices to Protect the Privacy of your Health Information” and attests to the following:

1. acknowledge that you have been provided access to the HIPAA Notice Form (a copy of the NOTICE is available at the check-in desk, from your case manager, and is also posted in the waiting area),
   
   
2. permit your case manager to consult with other health and mental health/social services professionals about your needs with the understanding that your case manager will make every effort to avoid revealing your identify during consultations,
   
   
3. acknowledge and understand that AGAPE staff must take action to protect serious threats to the life or safety of others. This will include reporting suspected abuse of a child or vulnerable adult, taking every reasonable step to prevent threats of violence against others from being carried out. You furthermore acknowledge that AGAPE will disclose information about you as necessary to comply with other legal requirements; such as responding to court ordered release of treatment records.

Your signature below indicates that you have received AGAPE’s “Notice of Clinicians’ Policies and Practices to Protect the Privacy of your Health Information” and attests to the following:

1. acknowledge that you have been provided access to the HIPAA Notice Form (a copy of the NOTICE is available at the check-in desk, from your case manager, and is also posted in the waiting area),
   
   
2. permit your case manager to consult with other health and mental health/social services professionals about your needs with the understanding that your case manager will make every effort to avoid revealing your identify during consultations,
   
   
3. acknowledge and understand that AGAPE staff must take action to protect serious threats to the life or safety of others.  This will include reporting suspected abuse of a child or vulnerable adult, taking every reasonable step to prevent threats of violence against others from being carried out.  You furthermore acknowledge that AGAPE will disclose information about you as necessary to comply with other legal requirements; such as responding to court ordered release of treatment records.