TELEPHONE COUNSELING NOTICE FORM
Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU OBTAINED DURING OUR TELEPHONE COUNSELING SESSION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
.Uses and Disclosures for Counseling, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI) for counseling, 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.
- “Counseling, Payment and Health Care Operations”
- Counseling is when I provide, coordinate or manage your health care and other services related to your health care. An example of counseling would be when I consult with another health care provider, such as your family physician or another psychologist.
- Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your credit card company 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 my 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 my practice group, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
- “Disclosure” applies to activities outside of my practice group, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of counseling, 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 I am asked for information for purposes outside of counseling, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your counseling notes. “Counseling notes” are notes I have made about our conversation during a private, group, joint, or family telephone counseling session, which I have kept separate from the rest of your counseling record. These notes are given a greater degree of protection than PHI.