Privacy Policy

Notice of Privacy Practices

for Matthew J. Bennett, Psy.D.

 

**This notice describes how psychological and medical information about you may be used and disclosed and how you can access this information.  Please review it carefully.**

 

I am required by applicable federal and state law to maintain the privacy of your personal health information (PHI) as part of providing professional care.  I am also required to give you this notice about my privacy practices, my legal duties, and your rights concerning your medical information.  I am required by law to keep your information private.  I must follow the privacy practices that are described in this notice while it is in effect.  This notices take effect 4/14/03, and will remain in effect until I replace it.  

 

I reserve the right to change my privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law.  I reserve the right to make the changes in my privacy practices and the new terms of my notice effective for all medical information that I maintain, including medical information I created or received before I made the changes.  Before I make a significant change in my privacy practices, I will change this notice and make the new notice available upon request.   You may request a copy of my notice at any time.  For more information about my privacy practices, or for additional copies of this notice, please contact me using the information listed at the end of this notice.

 

Organizations Covered by this Notice

 

This notice applies to the privacy practices of the organization listed below for delivery of health care products and services.  As such, I may share your medical information and the medical information of others I serve with each other as needed for treatment, payment or health care operations relating to my organized health care arrangement.  

 

Matthew J. Bennett, Psy.D., LLC

511 Broadway Street, Suite 2

Sheboygan Falls, WI  53085

 

Uses and Disclosures of Medical Information

 

I use and disclose medical information about you for treatment, payment, and health care operations. For example:

 

Treatment:  I may use your PHI to treat you or disclose it to a physician or other health care provider providing treatment to you.  This may only happen with your consent.   

 

Payment:  I may use and disclose your medical information/PHI to you or others to obtain payment for services I provide to you.

 

Your health care operations:

 

There are a few ways I may use or disclose your PHI for what are called health care operations.  For example, I may use your PHI to see where I can make improvements in the care and services I provide.  I may be required to supply some information to some government health agencies so they can study disorders and treatment and make plans for services that are needed.  If I do, your name and personal information will be removed from what I send. 

 

To You and on Your Authorization:  You may give me written authorization to use your medical information/PHI or to disclose it to anyone for any purpose.  If you give me an authorization, you may revoke it in writing at any time.  Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.  Unless you give me a written authorization, I cannot use or disclose your medical information/ for any reason except those described in this notice.  I must obtain your signed authorization prior to releasing your medical information/PHI for any uses and disclosures not described in my Privacy Notice.  I must obtain your signed authorization for disclosure of psychotherapy notes (in the case that I decide to create such notes).  

 

Business Associates:  There are some jobs that I may hire other businesses to do for me.  In the law, they are called Business Associates.  Examples include software vendors and billing agencies.  I have also designated a colleague to contact my clients in the event of my incapacitation or death to insure continuity of care.  This psychologist/counselor is Steven Meyers, Ph.D., ABPP.  These Business Associates need to receive some of your PHI to do their jobs properly if the situation arises.  To protect your privacy they will agree in their contract with me to safeguard your information.  

 

To Your Family and Friends:  I must disclose information to you, as described in the Individual Rights section of this notice.  I may disclose your medical information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree that I may do so.

 

Appointment Reminders:  I may use your medical information to contact you to provide appointment reminders or to reschedule.  

 

Persons Involved In Care:  I may use or disclose medical information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, your location, your general condition, or death.  If you are present, then prior to use or disclosure of your medical information, I will provide you with an opportunity to object to such uses or disclosures.  In the event of your incapacity or emergency circumstances, I will disclose protected health information based on a determination using my professional judgment disclosing only protected health information that is directly relevant to the person’s involvement in your health care. 

 

Disaster Relief:  I may use or disclose your medical information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts. 

 

Marketing Health Related Services:  I may use your medical information to contact you with information about health-related benefits and services or about treatment alternatives that may be of interest to you.  I may disclose your medical information to a business associate to assist me in these activities. 

 

Required by Law:  I may use or disclose your medical information when I am required to do so by law.  For example, I must disclose your medical information to the U.S. Department of Health and Human Services upon request for purposes of determining whether I am in compliance with federal privacy laws.  

-When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the HIPAA Privacy Rule and the state’s confidentiality law.  This includes narrowly-defined  disclosures to law enforcement agencies (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 and intelligence.  

 

Law Enforcement:  I may disclose your medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances.  Under limited circumstances, such as a court order, warrant, or grand jury subpoena, I may disclose your medical information to law enforcement officials.  I may disclose limited information to a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person.  I may disclose the medical information of an inmate or other person in lawful custody to a law enforcement official or correctional institution under certain circumstances.  

 

Abuse or Neglect:  I may disclose your medical information to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.  I may disclose your medical information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.  I may disclose medical information when necessary to assist law enforcement officials to capture an individual who has admitted to participation in a crime or has escaped from lawful custody.

 

National Security:  I may disclose to military authorities the medical information of Armed Forces personnel under certain circumstances.  I may disclose to authorized federal officials medical information required for lawful intelligence, counterintelligence, and other national security activities.  I may disclose to a correctional institution or law enforcement official having lawful custody of protected health information of inmate or individual under certain circumstances.  

 

Individual Rights

 

Access:  You may have the right to look at or get copies of medical information, with limited exceptions.  You may request that I provide copies in a format other than photocopies.  I will use the format you request unless I cannot practicably do so.  You must make a request in writing to obtain access to your medical information.  You may obtain a form to request access by using the contact information listed at the end of this notice.  You may also request access by sending me a letter to the address at the end of this notice.  You have a right to a copy of this notice.  If I change this NPP, I will provide you with a revised copy.  

 

Disclosure Accounting:  You have the right to receive a list of instances in which I disclosed your medical information/PHI for purposes, other than treatment, payment, health care operations or pursuant to an authorization and certain other activities, since April 14, 2003.  I will provide you with the date on which I made the disclosure, the name of the person or entity to whom I disclosed your medical information, a description of the medical information I disclosed, the reason for the disclosure, and certain other information.  If you request this accounting more than once in a 12-month period, I may charge you a reasonable, cost-based fee for responding to these additional requests.  Contact me using the information listed at the end of this notice for a full explanation of my fee structure.  

 

Breach Notification:  You have the right to be notified if:  (a) there is a breach (a use or disclosure of your medical information/PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised. 

 

Restriction:  You have the right to request that I place additional restrictions on our use or disclosure of your medical information/PHI.  You have the right to restrict certain disclosures of Protected Health Information (PHI) to a health plan if you pay out-of-pocket in full for the healthcare service.  

 

Confidential Communication:  You have the right to request that I communicate with you about your medical information by alternative means or to alternative locations.  You must make your request in writing, and you must state that the information could endanger you if it is not communicated by the alternative means or to the alternative location you want.  I must accommodate your request if it is reasonable, specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request.  

 

Amendment:  You have the right to request that I amend your medical information/PHI.  Your request must be in writing, and it must explain why the information should be amended. I may deny your request if I did not create the information you want amended and the originator remains available or for certain other reasons.  If I deny your request, I will provide you a written explanation.  You may respond with a statement of disagreement to be appended to the information you wanted amended.  If I accept your request to amend the information, I will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.  

 

Questions and Complaints

 

If you want more information about my privacy practices or have questions or concerns, please contact me using the information listed at the end of this notice.  

 

If you are concerned that I may have violated your privacy rights, or you disagree with a decision I made about access to your medical information/PHI or in response to a request you made to amend or restrict the use or disclosure of your medical information/PHI or to have me communicate with you by alternative means or at alternative locations, you may complain to me using the contact information listed at the end of this notice.  You also may submit a written complaint to the U.S. Department of Health and Human Services.  I will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.  

 

I support your right to the privacy of your medical information.  I will not retaliate in any way if you choose to file a complaint with me or with the U.S. Department of Health and Human Services.  

Contact Office:

Matthew J. Bennett, Psy.D., LLC

Address:  511 Broadway St., Suite 2, WI  53085

Telephone:  (425) 606-7548