CAPS Privacy Notice Form

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

The CAPS Staff may use or disclose your protected health information (PHI) for treatment and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

1) “PHI” refers to information in your health record that could identify you. Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and (1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and (i) That identifies the individual; or (ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual.”

2) “Treatment and Health Care Operations”

i) Treatment is when CAPS provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be when CAPS personnel consult with another health care provider, such as your family physician or another therapist.

ii) Health Care Operations are activities that relate to the performance and operation of CAPS services. 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.

iii) “Use” applies only activities within CAPS (office, clinic, practice group, etc.) such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

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

II. Uses and Disclosures Requiring Authorization

With your authorization, CAPS may use or disclose PHI for purposes outside of treatment and health care operations.

An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when CAPS is asked to provide information for purposes outside of treatment and health care operations, CAPS will obtain an authorization from you before releasing this information.

CAPS complies with the Code of Federal Regulations (CFR), Title 45, Volume 1 (45CFR164.524). This regulation states that you have a right of access to inspect and obtain a copy of your protected health information in a designated record set, for as long as the protected health information is maintained in the designated record set. There are several exceptions to access including, but not limited to, psychotherapy notes and information compiled in a reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding.

“Psychotherapy notes” are notes your therapist at CAPS has made about conversation during a private, group, joint, or family counseling session, which has been kept separate from the rest of your medical record.

You have a right to receive the following information: (1) medication prescription and monitoring; (2) counseling session start and stop times; (3) the modalities and frequencies of treatment furnished; (4) results of clinical tests; and, (5) any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis and prognosis to date.

CAPS may use or disclose PHI for purposes outside of treatment 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 CAPS is asked to provide information for purposes outside of treatment and health care operations, CAPS will obtain an authorization from you before releasing this information. You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) your therapist has relied on that authorization, or (2) 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

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

1) Child Abuse: When in a professional capacity, the CAPS staff has received information that gives us reason to believe that a child’s physical or mental health or welfare has been or may be adversely affected by abuse or neglect, we must report this information to the county Department of Social Services or to a law enforcement agency in the county where the child resides or is found. If we have received information in our professional capacity which gives us reason to believe that a child’s physical or mental health or welfare has been or may be adversely affected by acts or omissions that would be child abuse of neglect if committed by a parent, guardian, or other person responsible for the child’s welfare, but we believe that the act or omission was committed by a person other than the parent, guardian, or other person responsible for the child’s welfare, we must make a report to the appropriate law enforcement agency.

2) Abuse of a Vulnerable Adult: If CAPS staff has reason to believe that a vulnerable adult (i.e., an individual who is elderly, physically, or mentally disabled) has been or is likely to be abused, neglected, or exploited, we must report the incident within 24 hours or the next business day to the Adult Protective Services Program. We may also report directly to law enforcement personnel.

3) Health Oversight: The South Carolina Board of Examiners in Psychology and The South Carolina Medical Board have the power, if necessary, to subpoena your records. CAPS personnel is then required to submit to them those records relevant to their inquiry.

4) Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services CAPS provided you or the records thereof, such information is privileged under state law, and CAPS will not release information without your written consent 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.

5) Serious Threat to Health or Safety: If you communicate to the CAPS therapy/staff the intention to commit a crime or harm yourself, CAPS may disclose confidential information when they judge that disclosure is necessary to protect against a clear and substantial risk of imminent serious harm being inflicted on you or another person. In this situation, CAPS must limit disclosure of the otherwise confidential information to only those persons and only that content which would be consistent with the standards of the profession in addressing such problems.

6) Workers’ Compensation: If you file a workers’ compensation claim, CAPS is required by law to provide all existing information compiled by CAPS staff pertaining to the claim to your employer, the insurance carrier, their attorneys, the South Carolina Workers’ Compensation Commission, or me.

IV: Patient’s Rights and Mental Health Care Provider Duties

1) Patient’s Rights

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

b) 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 alterative means and at alternative locations. (For example, you may not want a family member to know that you are being seen at CAPS. Upon your request, we will send your correspondence to another address.)

c) Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis and prognosis to date. In compliance with 45CFR164.24, you will not have access to review nor receive copies of psychotherapy notes.

d) Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the records. In some instances, you may not be permitted to amend information. On your request, your therapist or the Director of CAPS will discuss with you the details of the amendment process.

e) Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, your therapist or the Director of CAPS will discuss with you the details of the accounting process.

f) Right to a Paper Copy – You have the right to obtain a paper copy of the notice from CAPS upon request, even if you have agreed to receive the notice electronically.

2) CAPS Therapy Staff Duties

a) We are 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.

b) We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, CAPS is required to abide by the terms currently in effect.

c) If CAPS revises our policies and procedures, we will post the revised policy in the CAPS waiting room and provide individuals with a printed copy upon request.

V. Complaints

If you are concerned that CAPS has violated your privacy rights or you disagree with a decision that was made about access to your records, you may contact Alice Q. Libet, Ph.D., CAPS Director, at (843) 792-4930 or Michael Wheeler, MUSC Privacy Officer at (843) 792-8744. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave., S.W., Washington, D.C. 20201, phone number 877-696-6775.

My acknowledgement below indicates that I have read and understand the Notice of Privacy Practice for MUSC Student Health Services and the Notice of Privacy for MUSC Counseling and Psychological Services. My acknowledgement also indicates that I have had ample opportunity to clarify any concerns I may have. I am also aware that a paper copy of this document is available upon request.
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.

Signature    

________________________________________  Date  ___________

Print Name 

 __________________________________________________________