SPECTRUM PRIVACY POLICY

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
Spectrum Psychotherapy Centers, LLC (Spectrum) 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 Spectrum provides, coordinate or manage your health care and other services related to your health care. An example of treatment would be when Spectrum consults with another health care provider, such as your family physician or another psychologist.

– Payment is when Spectrum obtains reimbursement for your healthcare. Examples of payment are when Spectrum discloses your PHI to your health insurer 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 Spectrum, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

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

II. Uses and Disclosures Requiring Authorization

Spectrum 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 Spectrum is asked for information for purposes outside of treatment, payment or health care operations,Spectrum will obtain an authorization from you before releasing this information. Spectrum will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your 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 (1) Spectrum 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

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

• Child Abuse – If Spectrum, in the ordinary course of the profession of psychology, Spectrum 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 Spectrum must report this suspicion or belief to the appropriate authority.

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

• Health Oversight Activities – If the Connecticut Board of Examiners of Psychologists is investigating this practice, 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 Spectrum 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 you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

• Serious Threat to Health or Safety – If Spectrum 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, Spectrum may disclose the appropriate information as permitted law.

• Worker’s Compensation – Spectrum may disclose protected health information 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 Psychologist’s Duties

Patient’s Rights:

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, Spectrum is not required to agree to a restriction you request.

• 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 Spectrum. On your request, Spectrum 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 our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Spectrum may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, Spectrum 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. Spectrum may deny your request. On your request, Spectrum 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. On your request, Spectrum 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 Spectrum upon request, even if you have agreed to receive the notice electronically.
Psychologist’s Duties:

• Spectrum is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

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

• If Spectrum revises my policies and procedures, Spectrum will notify you immediately by email or regular mail.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision Spectrum makes about access to your records, or have other concerns about your privacy rights, you may contact Spectrum. If you believe that your privacy rights have been violated and wish to file a complaint with Spectrum, you may send your written complaint to

Karel Rubinstein, Ph.D.
6 The Green
Canton, CT 06019-3172
phone 860-693-8020, fax 860-722-3089.

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. You have specific rights under the Privacy Rule. Spectrum will not retaliate against you for exercising your right to file a complaint.

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

This notice went into effect on April 14, 2003.