Hoffmann  Burchett Psychological Services, LLC - Therapy for Individuals, Couples, and Families
Privacy Practices
The Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) went into effect in an effort to regulate how patients' information may be used and/or disclosed. This notice describes how protected health information (PHI) about you may be used and shared, and how you can obtain access to this information. 
Please review it carefully.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations(PHI)
A.  Permissible Uses and Disclosures Without Your Written Authorization
Clinicians may use or disclose your protected health information (PHI), for treatment, payment, and health care operations with your consent. To help clarify, here are some definitions:
  • "PHI" refers to information in your clinical record that could identify you
  • Treatment is when a clinician provides, coordinates or manages your care. An example of treatment would be when she consults with another health care provider, such as your PCP or psychiatrist.
  • Payment is when the clinician obtains reimbursement for your health care. Examples of payment are when she discloses your PHI to your health insurer to obtain reimbursement or to determine eligibility or coverage.
  • Health Care Operations are activities that relate to the performance and operation of Hoffmann Burchett Psychological Services, LLC. Examples would include quality improvement activities, licensing, or credentialing requirements.
"Use" refers only to activities within the therapist office
"Disclosure" applies to activities outside of the therapist office, such as releasing information about you to other parties.
In addition, a clinician may use or disclose PHI without your consent or authorization in the following circumstances:
  • Child Abuse: If in her professional capacity, your therapist has reasonable cause to believe that a minor child is suffering physical, sexual or emotional abuse which causes the child harm or substantial risk of harm, the clinician must report such cases to the Department of Children and Family Services.
  • Adult and Domestic Abuse: If the clinician has reasonable cause to believe that an elderly person (age 60 or older) is suffering from or has died as a result of abuse, she must immediately report it to the Illinois Department of Elder Affairs.
  • Health Oversight: The Board of Professional Regulation of clinicians has the power, when necessary, to subpoena relevant records should your therapist be the focus of an inquiry.
  • Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis, treatment and the records thereof, such information is privileged under state law and your therapist will not release information without written authorization from you or your legally-appointed representative, or a court order.
  • Serious Threat to Health or Safety: If you communicate to your therapist an explicit threat to kill or inflict serious bodily injury upon an identified person and you have the apparent intent and ability to carry out the threat, your therapist must take reasonable precautions. Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization. She must also do so if she knows you have a history of physical violence and she believes there is a clear and present danger that you will attempt to kill or inflict bodily injury upon an identified person. Furthermore, if you present a clear and present danger to yourself and refuse to accept further appropriate treatment, and your therapist has a reasonable basis to believe that you can be committed to a hospital, your therapist must seek said commitment and may contact members of your family or other individuals if it would assist in protecting you.
  •  Worker’s Compensation: If you file a workers’ compensation claim, the records relevant to that claim will not be confidential to entities such as your employer, the insurer and the Division of Worker’s Compensation.
B. Uses and Disclosures Requiring  your Written Authorization
Your therapist may use or disclose PHI for purposes outside of treatment, payment, and health care operations only with your written authorization. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when a clinician is asked for information for purposes outside of treatment, payment and health care operations, she must obtain an authorization from you before releasing this information. She will also need to obtain an authorization before releasing her psychotherapy notes. "Psychotherapy notes" are notes the clinician might have made about conversations during a private, group, joint, or family counseling session, which she would have kept separate from the rest of your clinical record. These notes are given a greater degree of protection than PHI.
Uses and disclosures other than those described in Section IA above will be made only with your written authorization.  For example, you will need to sign an authorization form before a clinician may send PHI to your life insurance company, to a school, etc. 
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 once your therapist has already acted on it; 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.
II. Your Individual Rights and Therapist's Duties
 Patient’s Rights:
  1. Right to Inspect and Copy. You may request access to your medical record and billing records maintained by me in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, your clinician may deny access to your records. She may charge a fee for the costs of copying and sending you any records requested. If you are a parent or legal guardian of a minor, please note that certain portions of the minor’s medical record will not be accessible to you.
  2. Right to Alternative Communications. You may request, and your clinician will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.
  3. Right to Request Restrictions. You may have the right to request a restriction on PHI used for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to your clinician at the address listed below. Your clinician, however, is not required to agree to any such restriction you may request.
  4. Right to Accounting Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made by clinician. This right applies to disclosures for purposes other than treatment, payment or health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations.
  5. Right to Request Amendment. You have the right to request that your clinician amend your health information. Your request must be in writing, and it must explain why the information should be amended.  She may deny your request under certain circumstances.
  6. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to your clinician at any time.
  7. Questions and Complaints. If you desire further information about your privacy rights, or are concerned that your clinician may have violated your privacy rights you may contact the office: Hoffmann Burchett Psychological Services, LLC, 205 N. Williamsburg Drive, Suite F, Bloomington, IL 61704. Also, you may file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services.
Your clinician is required by law to maintain the privacy of PHI and to provide you with a notice of her legal duties and privacy practices with respect to PHI.
III. Effective Date, Restrictions and Changes to Privacy Policy
A.  Effective Date.  This Notice is effective as of November 1, 2010.
B.  Changes to this Notice.  Hoffmann Burchett Psychological Services, LLC reserves the right to change the privacy policies and practices described in this notice. Unless they notify you of such changes, however, they are required to abide by the terms currently in effect. If these policies and procedures are changed, they will post the revised notice in the office and at www.hoffmannburchett.com if applicable.  You may also contact the office to request a copy of the revised notice.
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