Neuropsychology Center of Louisiana, LLC, (NCLA)
Privacy Notice Form

Notice of Psychologist's Policies and Practices to Protect the Privacy of
Your Health Information

April 14, 2003

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

NCLA 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:
· "NCLA" refers to the staff of the Neuropsychology Center of Louisiana, LLC, including, but not limited to, Darlyne G. Nemeth, Ph. D, and all clinical and research assistants and associates, receptionist, business manager, and practice colleagues.

· "Practice Colleagues" refers to all practitioners who practice in the building known as the Drusilla Clinic.

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

· "Treatment, Payment, and Health Care Operations"
- Treatment is when NCLA provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when NCLA consults with other health care providers, such as your physicians or other psychologists/psychiatrists.
- Payment is when NCLA obtains reimbursement for your healthcare. Examples of payment are when NCLA discloses your PHI to your health insurer (including Workmen's Compensation) 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 NCLA's practice. 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 the NCLA/Drusilla Clinic such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. Example: You will be called to your appointment by your first name or a gesture; and your name will be kept in an appointment book along with other patient's names. (Every effort will be made to keep incidental disclosures to a minimum)

· "Disclosure" applies to activities outside of the NCLA/Drusilla Clinic, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

NCLA may use or disclose PHI for purposes outside of treatment, payment, or 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 NCLA is asked for information for purposes outside of treatment, payment or health care operations, NCLA will obtain an authorization from you before releasing this information. NCLA will also need to obtain an authorization before releasing your psychotherapy notes.

· "Psychotherapy Notes" are notes NCLA has made about conversations during a private, group, joint, phone, e-mail, or family counseling/therapy session, which NCLA has kept separate from the rest of your psychological/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
· NCLA has relied on that authorization; or

· 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

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

· Child Abuse - If NCLA has cause to believe that a child's physical or mental health or welfare is endangered as a result of abuse or neglect or that abuse or neglect was a contributing factor in a child's death, NCLA must report this belief to Louisiana Department of Social Services.

· Adult and Domestic Abuse - If NCLA has cause to believe that an adult's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation, NCLA must report this belief to the appropriate authorities as required by law. Please note that the term "adult", for the purposes of this section, means any person sixty years of age or older, any disabled person eighteen years of age or older, or any emancipated minor.

· Health Oversight Activities - Records may be subject to subpoena from NCLA relevant to its disciplinary proceedings and investigations.

· Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and NCLA will not release information without your written authorization, and/or a court order signed by a judge. A subpoena issued by a lawyer will no longer be considered adequate. In the event of your death, your legally-appointed representative will be given access if a suit is brought on behalf of the estate. The privilege does not apply when you are being evaluated by a third party or when the evaluation is court ordered. NCLA will inform you in advance if this is the case.

· Serious Threat to Health or Safety - If you communicate to NCLA a threat of physical violence, which NCLA deems to be significant, against a clearly identified victim or victims, coupled with the apparent intent and ability to carry out such threat, NCLA must take reasonable precautions to provide protection from the violent behavior. These precautions include communicating the threat to the potential victim(s) and notifying law enforcement.

· Worker's Compensation - If you file a worker's compensation claim and NCLA has treated you relevant to that claim, NCLA must disclose any requested psychological/medical information and records (including Psychotherapy Notes) relative to your injury to your employer, to a licensed and approved vocational rehabilitation counselor assigned to your claim, another health care provider examining you, and/or the worker's compensation insurer and/or agent.

IV. Patient's Rights and Psychologist's/Psychiatrist's Duties

Patient's Rights:

· Right to Request Restrictions -You have the right to request, in writing, restrictions on certain uses and disclosures of Protected Health Information (PHI). However, upon receipt of your written request, NCLA is not required to agree to the restriction(s) you have requested and/or to continue to provide services to you under the conditions imposed by this/these restriction(s).

· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request, in writing, 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 by NCLA at the Drusilla Clinic. On your request, NCLA 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 NCLA's psychological/medical and/or billing records used to make decisions about you for as long as the PHI is maintained in the record. NCLA may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. Upon receipt of your written request, NCLA 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. NCLA may deny your request. Upon receipt of your written request, NCLA 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. Upon receipt of your written request, NCLA 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 the notice from NCLA upon receipt of your written request, even if you have agreed to receive the notice electronically.

· Written Requests - All written requests must be properly signed, witnessed, and received (i.e. mailed or hand delivered to a specific NCLA staff member).

Psychologist's/Psychiatrists Responsibilities:

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

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

· If NCLA revises its policies and procedures, NCLA will provide individuals with a revised notice by mail.

· If NCLA perceives your "written right to request restrictions" on certain uses and disclosures of your PHI as too restrictive, NCLA reserves the right to discontinue your services here at the Drusilla Clinic. Upon your written request, alternative professional referrals will be provided.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision NCLA makes about access to your records, or have other concerns about your privacy rights, you may contact the NCLA/Drusilla Clinic privacy officer.

If you believe that your privacy rights have been violated and wish to file a complaint with the NCLA/Drusilla Clinic office, you may send your written complaint to the office addressed to the privacy officer.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Upon written request, the NCLA/Drusilla Clinic privacy officer can provide you with the appropriate address.

You have specific rights under the HIPAA Privacy Rule. Although NCLA may choose to refer you to another practitioner, no other actions will be taken against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

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

NCLA reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that NCLA maintains here at the Drusilla Clinic. If any revisions are made, NCLA will provide you with a revised notice by mail. It will be your responsibility, however, to keep NCLA informed of your currently preferred mailing address.

VII. Acknowledgement Of Receipt Of Notice Privacy Practices

I, _______________________________________, acknowledge that I have received a copy of the Notice of Privacy Practices.

__________________________________________
Signature of Patient

_______________________________
Signature of Patient

______________________________
Signature of Practitioner or Privacy Officer

NOTE: This form must be returned prior to or at the time of your session on or after April 14, 2003.

BY MAIL

mailed notice with confirmation

response received

no response

IN PERSON

notice explained

notice signed

notice refused