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Notice of Counseling and Psychological Services LLC’s Policies and Practices to Protect the Privacy of
Your Health Information


I. Uses and disclosures for Treatment, Payment, and Health Care Operations
Your psychologist may use or disclose your protected health information (PHI), for treatment,
payment, and healthcare operations purposes with your consent. To help clarify these terms,
here are some definitions:

● “PHI” refers to information in your health record which could identify you.
● “Treatment, Payment, and Health Care Operations”

○ Treatment is when your psychologist provides, coordinates, or manages
your healthcare and other services related to your health care. An
example of treatment would be when your psychologist consults with
another health care provider, such as your family physician or another
○ Payment is when your psychologist obtains reimbursement for your
health care. Examples of payment are when your psychologist 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
operations of the practice. Examples of healthcare operations are quality
assessment and improvement activities, business-related matters such
as audits and administrative services, and case management and care

● Use applies only to activities within Counseling and Psychological Services, LLC,
such as sharing, employing, applying, utilizing, examining, and analyzing
information that identifies you.
● Disclosure applies to activities outside of Counseling and Psychological Services,
LLC, such as releasing, transferring, or providing access to information about you
to other parties.

II. Uses and Disclosures Requiring Authorization

Your psychologist may use or disclose PHI for purposes outside of treatment, payment, or
healthcare 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 your psychologist is asked for information for purposes outside of treatment, payment, or
healthcare operations, your psychologist will obtain an authorization before releasing your psychotherapy
notes. Psychotherapy notes are selected notes your psychologist made about your conversations with
your psychologist during a private, group, joint, or family counseling session, which your psychologist has
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) your psychologist
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
Your psychologist may use or disclose PHI without your consent or authorization in the following

● Child Abuse-If your psychologist has reasonable cause to suspect that a child has been
or may be subjected to abuse or neglect, or if your pyschologist observes a child being
subjected to conditions which would reasonably result in abuse or neglect, your
psychologist must immediately report such information to the Missouri Division of Family
Services. Your psychologist must also report sexual abuse or molestation of a child less
than 18 years of age to Family Services. Your psychologist may also report child abuse
or neglect to a law enforcement agency or juvenile office.
● Adult and Domestic Abuse-If your psychologist has reasonable cause to suspect that an
eligible adult (defined by below) presents a likelihood of suffering physical harm or is in
need of protective services, your psychologist must report such information to the
Missouri Department of Social Services.

○ “Eligible Adult” means any person 60 years of age or older, or an adult with a
handicap (substantially limiting mental or physical impairment) between the ages
of 18 and 59 who is unable to protect their own interests or adequately perform
or obtain services which are necessary to meet their essential human needs.

● Health Oversight Activities-The Missouri Attorney General’s Office may subpoena
records from your psychologist relevant to disciplinary proceedings and investigations
conducted by the Missouri State Committee of Psychologists.
● Judicial and Administrative Proceedings-If you are involved in a court proceeding and a
request is made for information about your diagnosis or treatment and the records there
of, such information is privileged under state law, and your psychologist will not release
information without written authorization from you or your personal or legally appointed
representative, or by a court order. The privilege does not apply when you are being
evaluated for a third party or where the evaluation is court-ordered. Your psychologist
will inform you in advance if this were the case.
● Serious Threat to Health or Safety- When your psychologist judges that disclosure is
necessary to protect against a clear and substantial risk of imminent serious harm being
inflicted by you on yourself or another person, your psychologist must disclose your
relevant confidential information to the appropriate professional workers, public
authorities, the potential victim, their family or your family.
● Workers’ Compensation-If you file a worker’s compensation claim, your psychologist
must permit your record to be copied by Missouri Labor and Industrial Commission or the
Division of Worker’s Compensation of the Missouri Department of Labor and Industrial
Relations, your employer, you and any other party to the proceedings.

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, your psychologist is not
required to agree to a restriction that 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 your psychologist. On your request, your
psychologist 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 the mental health and billing records used to make decisions about you for as long as
the PHI is maintained in the record. Your psychologist may deny your access to PHI
under certain circumstances, but in some cases, you may have this decision reviewed.
On your request, your psychologist 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. Your psychologist may deny your request. On your
request, your psychologist 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, your psychologist 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 form your
psychologist upon request, even if you have agreed to receive the notice electronically.
Psychologist’s Duties:
● Your psychologist is required by law to maintain the privacy of PHI and to provide you
with a notice of their legal duties and privacy practices with respect to PHI.
● Your psychologist reserves the right to change the privacy policies and practices
described in this notice. Unless your psychologist notifies you of such changes, however,
your psychologist is required to abide by the terms currently in effect.
● If your psychologist revises these policies and procedures, your psychologist or office
personnel will notify you within one week of your first appointment following the changes.

V. Complaints

If you are concerned that your psychologist has violated your privacy rights, or you disagree with
a decision your psychologist made about access to your records, you may contact the Counseling and
Psychological Services, LLC HIPPA compliance officer at 573-446-5034.
You may also send a written complaint to the Secretary of the U.S. Department of Health and
Human Services. The person above can provide you with the appropriate address upon request.
This notice will go into effect April 1, 2015