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Notice of Privacy Practices

POLICIES AND PROCEDURES FOR HIPAA COMPLIANCE, effective October 2022

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW  INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE BE ADVISED THAT ALL MENTAL HEALTH AND SUBSTANCE ABUSE INFORMATION ABOUT YOU REQUIRES A SPECIFIC WRITTEN AUTHORIZATION SIGNED BY YOU PRIOR TO ITS RELEASE.  PLEASE REVIEW THIS DOCUMENT CAREFULLY.

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This Notice of Privacy Practices describes the legal obligations of The Center for Collaborative Family Therapy, PLLC and your legal rights regarding your protected health information held by the Company under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH Act). Among other things, this Notice describes how your protected health information may be used or disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law.

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We are required to provide this Notice of Privacy Practices to you pursuant to HIPAA.

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Use and Disclosure of PHI

Protected Health Information (“PHI”) may not be used or disclosed in violation of the Health Insurance Portability and Accountability Act (“HIPAA”) Privacy Rule (45 C.F.R. parts 160 and 164) (hereinafter, the “Privacy Rule”) or in violation of state law.

 

The Center for Collaborative Family Therapy, PLLC is permitted, but not mandated, under the Privacy Rule to use and disclose PHI without client consent or authorization in limited circumstances. However, state or federal law may supersede, limit, or prohibit these uses and disclosures.

 

Under the Privacy Rule, these permitted uses and disclosures include those made:

 

  • To the client

  • For treatment, payment, or health care operations purposes, or

  • As authorized by the client.

 

Additional permitted uses and disclosures include those related to or made pursuant to:

 

  • Reporting on victims of domestic violence or abuse, as required by law

  • Court orders

  • Workers' compensation laws

  • Serious threats to health or safety

  • Government oversight (including disclosures to a public health authority, coroner or medical examiner, military or veteran's affairs agencies, an agency for national security purposes, law enforcement)

  • Health research

  • Marketing or fundraising.

 

The Center for Collaborative Family Therapy, PLLC does not use or disclose PHI in ways that would be in violation of the Privacy Rule or state law. The Center for Collaborative Family Therapy, PLLC uses and discloses PHI as permitted by the Privacy Rule and in accordance with state or other law. In using or disclosing PHI, The Center for Collaborative Family Therapy, PLLC meets the Privacy Rule’s “minimum necessary requirement,” as appropriate.

 

Use and Disclosure of PHI—Minimum Necessary Requirement

When using, disclosing, or requesting PHI, The Center for Collaborative Family Therapy, PLLC makes reasonable efforts to limit PHI to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request. The Center for Collaborative Family Therapy, PLLC recognizes that the requirement also applies to covered entities that request client records and requires that such entities meet the standard, as required by law.

 

The minimum necessary requirement does not apply to disclosures for treatment purposes or when The Center for Collaborative Family Therapy, PLLC shares information with a client. The requirement does not apply for uses and disclosures when client authorization is given. It does not apply for uses and disclosures as required by law or to uses and disclosures that are required for compliance with the Privacy Rule.

 

Disclosure will be made on a case-by-case basis using the criterion of whatever is reasonably necessary to accomplish the purpose for which the request is made.

 

Exceptional Instances: The Center for Collaborative Family Therapy, PLLC may rely, if such reliance is reasonable under the circumstances, on a requested disclosure as the minimum necessary for the stated purpose, if the PHI is requested by another covered entity, by a public official (who represents that the information requested is the minimum necessary), or by a researcher (with appropriate documentation).

 

The Center for Collaborative Family Therapy, PLLC may rely, if such reliance is reasonable under the circumstances, on a requested disclosure as the minimum necessary for the stated purpose, if the PHI is requested by a member of CCFT staff or business associate.

 

The Center for Collaborative Family Therapy, PLLC will not use, disclose, or request an entire medical record, except when the entire medical record is justified as the amount that is reasonably necessary to accomplish the purpose of the use, disclosure, or request.

 

Use and Disclosure of PHI—Psychotherapy Notes Authorization

The Center for Collaborative Family Therapy, PLLC abides by the Psychotherapy Notes authorization requirement of the Privacy Rule, unless otherwise required by law. In addition, authorization is not required in the following circumstances:

 

  • For our use for treatment

  • For use or disclosure in supervised training program where trainees learn to practice counseling

  • To defend against a legal action brought by the client who is the subject of the PHI

  • For purposes of HHS in determining our compliance with the Privacy Rule

  • By health oversight agency for a lawful purpose related to oversight of our practice

  • To a coroner or medical examiner

  • In instances of permissible disclosure related to a serious or imminent threat to the health or safety of a person or public.

 

All clients that are being considered for psychotherapy will be given a form explaining HIPAA compliance and asked to provide a signed authorization agreement, which is kept in the client chart. The client may revoke an authorization at any time in writing, except to the extent that The Center for Collaborative Family Therapy, PLLC has, or another entity has, already taken action in reliance on the authorization.

 

Psychotherapy notes will be kept separately from the normal medical record, and are the responsibility of the treating clinician. Notes from completed cases will be stored in a separate file cabinet or box. Psychotherapy notes may be released only when a valid authorization has been signed by the client and received by our office. An authorization is considered valid when:

  1. It is completely filled out and contains no false information

  2. It is separate from other authorizations (i.e., not a blanket release)

  3. Is written in plain language that is unlikely to mislead the client

  4. It contains a statement adequate to put the client on notice that:

 

  • He or she may revoke the authorization in writing and either exceptions to such right and a description of how to revoke, or a reference to revocation in the notice provided to the client;

  • Treatment, payment, enrollment, or eligibility for benefits may not be contingent on the authorization;

  • Protected confidential information could possibly be re-disclosed by other and no longer protected by the rule.

 

  5. A valid authorization must also contain the following specific information:

 

  • A description of the information to be used and disclosed that identifies the  information in a specific and meaningful fashion.

  • The name or other specific identification of the person(s), or class of person, authorized to make the requested use and disclosure (i.e., "From" information).

  • The name or other specific identification of the person(s), or class of persons, to whom the requested use and disclosure will be made(i.e.,“To” information).

  • A description of each purpose of the requested use or disclosure.The statement “at the request of the individual” is a sufficient description of the purpose when a client initiates the authorization and does not, or elects not to, provide a statement of the purpose.

  • An expiration date that relates to the individual or the purpose of the use or disclosure.

  • A signature (or if signed by a personal representative, a description of authority to sign) and date.

 

 

Client Rights—Notice

As required under the Privacy Rule, and in accordance with state law, The Center for Collaborative Family Therapy, PLLC provides notice to clients of the uses and disclosures that may be made regarding their PHI and our duties and client rights with respect to the notice. The Center for Collaborative Family Therapy, PLLC makes a good faith effort to obtain written acknowledgment that our clients receive this notice.

 

The Center for Collaborative Family Therapy, PLLC provides notice to clients on the first date of treatment. In an emergency situation, The Center for Collaborative Family Therapy, PLLC provide notice “as soon as reasonably practicable.” (This first date of treatment timing requirement applies to electronic service delivery, and a client may request a paper copy of notice when services are electronically delivered.)

 

Except in emergency situations, The Center for Collaborative Family Therapy, PLLC makes a good faith effort to obtain from a client written acknowledgement of receipt of the notice. If the client refuses or is unable to acknowledge receipt of notice, The Center for Collaborative Family Therapy, PLLC documents why an acknowledgement was not obtained.

 

The Center for Collaborative Family Therapy, PLLC promptly revises and distributes notice whenever there is a material change to uses and disclosures, client’s rights, legal duties of the Center for Collaborative Family Therapy, PLLC, or other privacy practices stated in the notice.

 

The Center for Collaborative Family Therapy, PLLC makes notice available in our office for clients to take with them and posts the notice in a clear and prominent location.

 

Client Rights—Restrictions and Confidential Communications

The Privacy Rule permits clients to request restrictions on the use and disclosure of PHI for treatment, payment, and health care operations, or to family members. While is not required to agree to such restrictions, The Center for Collaborative Family Therapy, PLLC will attempt to accommodate a reasonable request. Once The Center for Collaborative Family Therapy, PLLC has agreed to a restriction, that restriction may not be violated; however, restricted PHI may be provided to another health care provider in an emergency treatment situation.

 

A restriction is not effective to prevent uses and disclosures when a client requests access to his or her records or requests an accounting of disclosures. A restriction is not effective for any uses  and disclosures authorized by the client, or for any required or permitted uses recognized by law.

 

The Privacy Rule also permits clients to request receiving communications from us through alternative means or at alternative locations. As required by the Privacy Rule, The Center for Collaborative Family Therapy, PLLC will accommodate all reasonable requests.

 

Client Rights—Access to and Amendment of Records

In accordance with state law, the Privacy Rule, and other federal law, clients have access to and may obtain a copy of the  medical and billing records that The Center for Collaborative Family Therapy, PLLC maintain. Clients are also permitted to amend their records in accordance with such law.

 

Client Rights— Accounting of Disclosures

The Center for Collaborative Family Therapy, PLLC provides clients with an accounting of disclosures upon request, for disclosures made up to six years prior to the date of the request. While The Center for Collaborative Family Therapy, PLLC may, it does not have to provide an accounting for disclosures made for treatment, payment, or health care operations purposes, or pursuant to client authorization. The Center for Collaborative Family Therapy, PLLC also does not have to provide an accounting for disclosures made for national security purposes, to correctional institutions or law enforcement officers, or that occurred prior to April 14, 2003.

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Business Associates

The Center for Collaborative Family Therapy, PLLC relies on certain persons or other entities, who or which are not employees, to provide services on the Center’s behalf. These include Simple Practice, Zoom, Gmail. Where these persons or entities perform services that require the disclosure of individually identifiable health information, they are considered under the Privacy Rule to be business associates.

 

The Center for Collaborative Family Therapy, PLLC enters into a written agreement with each business associate to obtain satisfactory assurance that the business associate will safeguard the privacy of the client PHI. The Center for Collaborative Family Therapy, PLLC relies on business associates to abide by the contract but will take reasonable steps to remedy any breaches of the agreement that The Center for Collaborative Family Therapy, PLLC becomes aware of. Enclosed are copies of the completed contracts.

 

Administrative Requirement—Privacy Officer

The Center for Collaborative Family Therapy, PLLC designates Jennifer King, PhD, LMFT as privacy officer, who is responsible for the development and implementation of the policies and procedures to protect PHI, in accordance with the requirements of the Privacy Rule. As the contact person for clinical practice, the privacy officer receives complaints and fulfills obligations as set out in the notice to clients.

 

Administrative Requirement—Training

As required by the Privacy Rule, The Center for Collaborative Family Therapy, PLLC trains all staff members as necessary and appropriate to carry out their functions on the policies and procedures to protect PHI. The Center for Collaborative Family Therapy, PLLC has the discretion to determine the nature and method of training necessary to ensure that staff appropriately protect the privacy of client records.

 

Administrative Requirement—Safeguards

To protect the privacy of the client PHI, The Center for Collaborative Family Therapy, PLLC has in place appropriate administrative, technical, and physical safeguards, in accordance with the Privacy Rule.

 

Administrative Requirement—Complaints

The privacy of client PHI is critically important for relationships with clients and for clinical practice. The Center for Collaborative Family Therapy, PLLC provides a process for clients to make complaints concerning adherence to the requirements of the Privacy Rule.

 

Administrative Requirement—Sanctions

Although The Center for Collaborative Family Therapy, PLLC will apply appropriate sanctions against a member of our staff who fails to comply with the requirements of the Privacy Rule or our policies and procedures, we may not apply sanctions against an individual who is testifying, assisting, or participating in an investigation, compliance review, or other proceeding.

 

Administrative Requirement—Mitigation

The Center for Collaborative Family Therapy, PLLC mitigates, to the extent possible, any harmful effect that The Center for Collaborative Family Therapy, PLLC becomes knowledgeable of regarding use or disclosure, or business associate’s use or disclosure, of PHI in violation of policies and procedures or the requirements of the Privacy Rule.

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Administrative Requirement—Retaliatory Action and Waiver of Rights

The Center for Collaborative Family Therapy, PLLC believes that clients should have the right to exercise their rights under the Privacy Rule. The Center for Collaborative Family Therapy, PLLC does not take retaliatory action against a client for exercising his or her rights or for bringing a complaint. Of course, The Center for Collaborative Family Therapy, PLLC will take legal action to protect itself, if The Center for Collaborative Family Therapy, PLLC believes that a client has undertaken an activity in bad faith.

 

The Center for Collaborative Family Therapy, PLLC will not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against a client for exercising a right, filing a complaint or participating in any other allowable process under the Privacy Rule.

 

The Center for Collaborative Family Therapy, PLLC will not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against a client or other person for filing an HHS compliance complaint, testifying, assisting, or participating in a compliance review, proceeding, or hearing, under the Administrative Simplification provisions of HIPAA.

 

The Center for Collaborative Family Therapy, PLLC will not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against a client or other person for opposing any act or practice made unlawful under the Privacy Rule, provided that the client or other person has a “good faith belief” that the practice is unlawful and the manner of opposition is reasonable and does not involve disclosure of PHI.

 

The Center for Collaborative Family Therapy, PLLC will not require a client to waive his or her rights provided by the Privacy Rule or his or her right to file an HHS compliance complaint as a condition of receiving treatment.

 

Administrative Requirement—Policies and Procedures

To ensure that is in compliance with the Privacy Rule, The Center for Collaborative Family Therapy, PLLC has implemented policies and procedures to ensure compliance with the Privacy Rule.

 

Administrative Requirement—Documentation

The Center for Collaborative Family Therapy, PLLC meets applicable state laws and the Privacy Rule’s requirements regarding documentation.

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This document was last updated: April 29, 2024

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