PENNSYLVANIA NOTICE OF PATIENT PRIVACY
Notice of Policies and Practices of Cognizant Behavioral Health Services 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
Cognizant Behavioral Health Services (CBHS) 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.
· "Treatment, Payment, and Health Care Operations"
o Treatment is when CBHS provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be when your CBHS provider consults with another health care provider, such as your family physician or another psychologist.
o Payment is when CBHS obtains reimbursement for your healthcare. Examples of payment are when CBHS discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
o Health Care Operations are activities that relate to the performance and operation of CBHS. 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 CBHS, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· "Disclosure" applies to activities outside of CBHS, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
CBHS 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 CBHS is asked for information for purposes outside of treatment, payment, and health care operations, we will obtain an authorization from you before releasing your PHI including medication reviews and psychotherapy notes. You may revoke all such authorizations of PHI at any time, provided such revocation is in writing. You may not revoke an authorization to the extent that (1) CBHS 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.
III. Uses and Disclosures with Neither Consent nor Authorization
CBHS and its mental health care providers may use or disclose PHI without your consent or authorization in the following circumstances:
· Child Abuse: If an CBHS provider has reasonable cause, on the basis of his/her professional judgment, to suspect abuse of children with whom the provider comes into contact in his/her professional capacity, or who are treated by another CBHS provider, the provider is required by law to report this to the Pennsylvania Department of Public Welfare.
· Adult and Domestic Abuse: If an CBHS provider has reasonable cause to believe that an older adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), the provider may report such to the local agency which provides protective services.
· Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services you received at CBHS, or the records thereof, such information is privileged under state law, and CBHS 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 present or express a serious threat or intent to kill or seriously injure an identified or readily identifiable person or group of people, and your CBHS provider determines that you are likely to carry out the threat, the provider must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of the threat or intent.
· Worker's Compensation: If you file a worker's compensation claim, CBHS will be required to file periodic reports with your employer which shall include, where pertinent, history, diagnosis, treatment, and prognosis.
IV. Patient's Rights and CBHS’s Duties Patient's Rights:
· Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, CBHS 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. (For example, you may not want a family member to know that you are being seen at CBHS. Upon your request, CBHS will send your bills to another address.)
· Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI in CBHS’s clinical and billing records used to make decisions about you for as long as the PHI is maintained in the record. CBHS may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, CBHS staff 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. CBHS may deny your request. On your request, CBHS staff 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 for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, CBHS staff will discuss with you the details of the accounting process.
· Right to a Paper Copy - You have the right to obtain a paper copy of this Notice from CBHS upon request, even if you have agreed to receive the Notice electronically.
· CBHS 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.
· CBHS reserves the right to change the privacy policies and practices described in this Notice. Unless CBHS notifies you of such changes, however, it is required to abide by the terms currently in effect.
· If CBHS revises its policies and procedures, it will provide clients with a revised notice by mail.
V. Amendments to Privacy Notice effective May 11, 2017.
· If there is a breach of your confidentiality, then CBHS must inform you as well as Health and Human Services. A breach means that information has been released without authorization or without legal authority unless CBHS can show that there was a low risk that the PHI has been compromised because the unauthorized person did not view the PHI or it was de-identified.
· If you are self-pay, then you may restrict the information sent to insurance companies.
· Most uses and disclosures of psychotherapy notes and of protected health information for marketing purposes and the sale of protected health information require an authorization. Other uses and disclosures not described in the notice will be made only with your written authorization. You must sign an authorization (release of information form) for releases that are not mentioned in this Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired drivers, etc.).
VI. Questions and Complaints
If you have questions about this notice, disagree with a decision CBHS makes about access to your records, or have other concerns about your privacy rights, you may contact Manisha Kamat, MD - Privacy Officer, at 610-361-9500.
If you believe that your privacy rights have been violated and wish to file a complaint with CBHS, you may send your written complaint to Cognizant Behavioral Health Services, Privacy Officer, 6 Dickinson Dr. #107 Chadds Ford PA 19317.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The privacy officer listed above can provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. CBHS will not retaliate against you for exercising your right to file a complaint.
STATEMENT OF THE RIGHTS AND RESPONSIBILITIES OF PATIENTS
Part I: The Patient’s Bill of Rights
Every patient has the following basic rights:
1. The patient has the right to be treated with respect and dignity.
2. The patient must have the assurance that all patient information, including the content of therapy sessions and the written record of treatment, is considered confidential, and may not be shared with anyone without the patient’s written permission, except in situations where disclosure is required by law or court order. These exceptional situations include 1) when the provider believes the patient presents an imminent danger to self or others; 2) when there is reasonable suspicion of child or elder abuse or neglect; 3) when the patient is an impaired driver; and 4) when a judge orders the release of the patient’s record or the testimony of the provider as part of a legal proceeding. In these specific situations, the provider will do what he or she can, within the limits of the law, to prevent the patient from harming self or others, and to ensure that the patient receives proper care. We are also mandated to report disclosure by a client admitting to abusing a child, even if that child is no longer in danger. By signing this form, the patient consents to have his/her therapist consult with CBHS clinical staff if the clinical need arises and the patient also acknowledges that CBHS support staff has access to all files. If patient is referred to another professional within this practice, the clinical staff will consult regarding his/her case.
3. The patient has the right to a complete and easily understood explanation of his or her condition and treatment.
4. The patient has the right to participate in decisions involving his or her treatment.
5. The patient has the right to be informed of the consequences of refusing treatment or not complying with prescribed treatment.
6. The patient has the right to participate or not to participate in scientific research.
7. The patient has the right to file a grievance should a dispute arise over treatment or claims.
8. The patient has the right to know all about the terms of treatment, such as its cost, method of payment, appointment times, privacy issues, and cancellation policies.
9. The patient has the right to have any therapy procedure or method explained to them before it is used.
10. The patient has the right to end therapy at any time. After the first one or two meetings, the provider will assess whether he or she can help the patient meet the therapeutic goals. If the provider believes that the patient’s treatment needs would be better met by another mental health provider with particular skills or experience, the provider will recommend another provider. If at any point during treatment, the provider determines that he or she is not being effective in helping the patient reach therapeutic goals, he or she will discuss this with the patient, and if appropriate, terminate the treatment. In such a case, the provider will make a recommendation for another provider who may be able to help the patient address therapeutic goals.
Part II: The responsibilities of Patients
The purpose of patient’s responsibilities is to ensure quality of care and proper use of health care resources. These responsibilities include the following:
1. The patient should exercise courtesy and make every effort to keep scheduled appointments.
2. The patient must present true and accurate information when it is requested.
3. The patient must pay any necessary fees at the time of the appointment unless an alternative arrangement has been agreed upon.
4. The patient must give 24 hours advance notice of session cancellation. If a patient fails to show or cancels with less than 24 hours’ notice, the patient will be charged $75 no show fee.
5. If patient chooses to communicate with the treating professional via text or E-mail, patient understands that such communications are not HIPAA compliant. Therefore, it is recommended that if patient chooses to communicate with their clinician via these methods, please limit the communication to scheduling and to not share treatment related information.
Signature on File
A. I give this office permission to release any information obtained during examinations or treatment of this patient that is necessary to support any insurance claims on this account and secure timely payments due to the assignee or myself.
B. I understand that I am responsible for all charges, regardless of insurance coverage.
C. Assignment of benefits
I hereby assign medical benefits, including those from government-sponsored programs and other health plans, to be paid to the provider/practice above. Medicare regulations may apply. A photocopy of this assignment is to be considered as good as the original.