Serving Phoenix, AZ
202 E. Earll Drive #420Phoenix, AZ 85012
Privacy Policies
Dr. Vaughn Tsoutsouris, PLLC
Clinical Psychologist
NOTICE OF PRIVACY PRACTICES: ARIZONA NOTICE FORM
Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information
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.
I am required by law to maintain the privacy of your protected health information and to provide you with this notice, which explains my legal duties and privacy practices with respect to your protected health care information. I must abide by the terms set forth in this notice. However, I reserve the right to change the terms of this notice and make new notice of provisions effective for all protected health information.
- Uses and Disclosures for Treatment, Payment, and Health Care Operations
- PHI: refers to information in your health record that could identify you- Treatment, Payment and Health Care Operations: Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment 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 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 case coordination. I may also disclose your PHI to third-party business associates who perform certain activities for me (e.g. billing services)- Use: Activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you- Disclosure: Activities outside of my office 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 treatment, payment, or health care operations when you 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 treatment, payment or health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization prior to releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I 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) I have relied on that authorization; 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.
I will also obtain an authorization from you before using or disclosing:
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) I have relied on that authorization; 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.
I will also obtain an authorization from you before using or disclosing:
- PHI in a way that is not described in this Notice
III. Uses and Disclosures with Neither Consent not Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
- Serious Threat to Health of Safety: If you communicate to me an explicit threat of imminent serious physical harm or death to a clearly identifiable victim(s) and I believe you have the intent and ability to carry out such a threat, I have duty to take reasonable precautions to prevent the harm from occurring, including disclosing information to the potential victim and the police and in order to initiate hospitalization procedures. If I believe there is an imminent risk that you will inflict serious harm on yourself, I may disclose information in order to protect you (e.g. to initiate hospitalization procedures).- Child Abuse: I am required to report PHI to the appropriate authorities when I have reasonable grounds to believe that a minor is or has been the victim of neglect or physical and/or sexual abuse- Adult and Domestic Abuse: If I have the responsibility for the care of an incapacitated or vulnerable adult, I am required to disclose PHI when I have reasonable basis to believe that abuse or neglect of the adult has occurred or that exploitation of the adult’s property has occurred- Health Oversight Activities: If the Arizona Board of Psychological Examiners is conducting an investigation, then I am required to disclose PHI upon receipt of a subpoena from the board- Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services I provided you and/or the records there of, such information is privileged under state law, and I will not release information without a court order or the written authorization of you or your legally appointed representative. 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.- Worker’s Compensation: I may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker’s comp or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault- When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.52 of the Privacy Rule and the State’s confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security agency.
- PHI: refers to information in your health record that could identify you- Treatment, Payment and Health Care Operations: Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment 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 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 case coordination. I may also disclose your PHI to third-party business associates who perform certain activities for me (e.g. billing services)- Use: Activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you- Disclosure: Activities outside of my office such as releasing, transferring, or providing access to information about you to other parties
- PHI: refers to information in your health record that could identify you- Treatment, Payment and Health Care Operations: Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment 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 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 case coordination. I may also disclose your PHI to third-party business associates who perform certain activities for me (e.g. billing services)- Use: Activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you- Disclosure: Activities outside of my office such as releasing, transferring, or providing access to information about you to other parties
IV. Patent’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 certain PHI (e.g., to persons involved with your care, or for notification purposes as set forth in this notice). However, I am not required to agree to the restrictions you request. If I do agree, I will comply with your request unless the information is needed for emergencies
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 locations (for example, you may not want a family member to know that you are seeing me). On your request, I will send your bills to another address. You must submit your request in writing.
Right to Inspect and Copy: You have the right to inspect and/or obtain a copy of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. At your request, I will discuss with you the details of the request and the denial process. If you wish to inspect or copy your medical information, you must submit your request in writing to my attention at the address referenced at the end of this notice. I will charge a fee in fulfilling your request. I will notify you of such costs and afford you the opportunity to withdraw your request before any costs are incurred. I have 30 days to respond to information that I maintain at my practice site, starting from the date of receipt of written request.
Right to Amend: You have the right to request an amendment of PHI as long as the PHI is maintained in the record. You must make this request in writing. The request must state the reasons for the amendment. I may deny your request if the information: 1) was not created by me; 2) is not part of the record you are permitted to inspect and copy; 3) is not part of my designated record; or 4) is already accurate and complete. On your request, I will discuss with you the process of the amendment process.
Right to Accounting: You generally have the right to receive an accounting of disclosures of PHI except for 1) disclosures made to you; 2) disclosures for treatment, payment, or health care operations 3) incidents to a use or disclosure set forth in this notice; 4) disclosures made to law enforcement officials; or 5) information used as part of a limited data set, that occurred before April 14, 2003 or 6 years or more from the date of your request. Your request must be made in writing and must state the time period for the requested information. I may charge you a fee for your request. I will notify you of such costs and afford you the opportunity to withdraw your request before any costs are incurred. On your request, I will discuss with you the details of the accounting process.
Right to Paper Copy: You have the right to obtain a paper copy of this notice from me upon your request, even if you have agreed to receive the notice electronically.
Right to Restrict Disclosures When you have Paid for your Care Out-of-Pocket: You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.
Right to be Notified if there is a Breach of Your Unsecured PHI. You have the right to be notified if: 1) there is a breach (a use of disclosure of your PHI in violation of HIPPA Privacy rule) involving your PHI; 2) that PHI has not been encrypted to government standards; and 3) my risk assessment fails to determine that there is a low probability your PHI has been compromised.
Right to be Notified if there is a Breach of Your Unsecured PHI. You have the right to be notified if: 1) there is a breach (a use of disclosure of your PHI in violation of HIPPA Privacy rule) involving your PHI; 2) that PHI has not been encrypted to government standards; and 3) my risk assessment fails to determine that there is a low probability your PHI has been compromised.
Psychologist’s Duties:
I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the current terms in effect.
I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the current terms in effect.
V. Complaints
If you are concerned that I have violated your privacy rights or you disagree with a decision I made about access to your records, you may contact me at the address listed below. You may also send a written complaint to: Office of the Secretary, U.S. Department and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201.
VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice is effective January 2, 2017. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me at the address listed in the letterhead of this notice. You may also sent a written complaint to: Office of the Secretary, U.S. Department and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me at the address listed in the letterhead of this notice. You may also sent a written complaint to: Office of the Secretary, U.S. Department and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201.
Vaughn Tsoutsouris, Psy.D.202 E. Earll Drive #420Phoenix, AZ, 85012(602) 499-6695Fax: 844-647-8716
Patient
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Patient Signature of Legal Guardian Signature
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Witness
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