I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Maine & Weinstein Specialty Group LLC (MWSG) 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”
  * Treatment is when MWSG provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when MWSG consults with another health care provider, such as your family physician or another psychologist.
  * Payment is when MWSG may aid you in obtaining reimbursement for your healthcare. Examples of this are when MWSG might disclose your PHI to your health insurer to help you 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 MWSG. 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 MSWG such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• "Disclosure” applies to activities outside of MWSG, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

Maine & Weinstein Specialty Group LLC may only use or disclose PHI when your appropriate authorization is obtained. An “authorization” is written permission that permits specific disclosures. In instances when MWSG is asked for information, an authorization from you will be obtained before releasing this information. MWSG will also obtain an authorization before releasing Psychotherapy Notes. “Psychotherapy Notes” are notes made about conversations during a private, group, joint, or family counseling session, which are kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. The only exception to this would involve the release of the name, address, and amount of fees owed, to a third party for the purpose of collection of delinquent fees. The patient would be notified in writing not less than thirty days prior to such disclosure.

You may revoke all such authorizations of PHI at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) an MWSG clinical staff member has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

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

• Child Abuse – If any MWSG clinical staff member, in the ordinary course of his/her duties, has reasonable cause to suspect or believe that any child under the age of eighteen years (1) has been abused or neglected, (2) has had nonaccidental physical injury, or injury which is at variance with the history given of such injury, inflicted upon such child, or (3) is placed at imminent risk of serious harm, then that professional must report this suspicion or belief to the appropriate authority.

• Adult and Domestic Abuse – If any MWSG clinical staff member knows or in good faith suspects that an elderly individual or an individual who is disabled or incompetent, has been abused, that staff member may disclose the appropriate information as permitted by law.

• Health Oversight Activities – If the Connecticut Board of Examiners of Psychologists is investigating MWSG, the board may subpoena records relevant to such investigation.

• 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 MWSG will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when the evaluation is court ordered. You will be informed in advance if this is the case.

• Serious Threat to Health or Safety – If any MWSG clinical staff member believes in good faith that there is risk of imminent personal injury to you or to other individuals or risk of imminent injury to the property of other individuals, that staff member may disclose the appropriate information as permitted by law.

• Worker’s Compensation – MWSG may disclose PHI regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

IV. Patient’s Rights and Clinical Staff Duties

Patient’s Rights:

Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of PHI. However, MWSG is not required to agree to a restriction you request. Any requests for restrictions must be made in writing to an MWSG staff member.

• 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 clinical staff member at MWSG. On your request, MWSG 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 MWSG mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Requests to inspect or copy PHI must be made in writing to an MWSG staff member. MWSG may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, an MWSG clinical staff member 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. Any request to amend must be made in writing to MWSG staff. MWSG may deny your request. On your request, an MWSG clinical staff member 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 that was provided with neither consent or authorization. Upon your written request, an MWSG clinical staff member 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 MWSG upon request, even if you have agreed to receive the notice electronically.

Staff Duties:

• All staff members at MWSG are required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.

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

• If MWSG revises its policies and procedures, notice of these revisions will be provided in writing to all patients by mail.

V. Complaints

If you are concerned that any staff member at MWSG has violated your privacy rights, or you disagree with a decision that MWSG has made about access to your records, you may contact Robert J. Weinstein, Ph.D. at (860) 313-4431.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

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

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

MWSG reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that is maintained by MWSG. MWSG will provide you with a revised notice by mail.
 

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