SMDC PSYCHOTHERAPY SERVICE PRIVACY POLICY

HIPAA Privacy Notice

Disclosure of Use Information Within Sharon M Dossett Consulting, LLC. The Federal Health Insurance Portability and Accountability Act (HIPAA, at 45 CFR Parts 160 and 164) requires that all persons given any Health services, including initial evaluation, receive a notice of our privacy policies (as contained in this document) regarding the storage, use, and transmission of their Protected Health Information (PHI).

• This form is a general HIPAA disclosure of the use of information at Sharon M Dossett Consulting, LLC and it does not permit your information to be sent to any other person except for the purposes of billing and collection and for treatment-related operations within the clinic. However, certain entities set forth in Wisconsin Statutes Chapter 51, such as the clinic licensing division, Medicaid auditors, quality auditors, the County coroner, and other oversight agencies, who are bound to maintain a high level of confidentiality, may audit our files for certain statutory reasons, such as quality audits or funding audits or other reasons.
  
• When we transmit information to insurance companies, they are bound by the same rules.
  
• When we store information, we keep computer files in password protected secure servers.
  
• Our computer files are password protected and, when necessary, firewall protected.
  
• Our electronic communications are sent to secure sites or, when we communicate with you by email, your permission is required before non-encrypted communications take place.
  
• Our staff has been trained in HIPAA confidentiality procedures.
  

Disclosures Within Sharon M Dossett Consulting, LLC. Your signature below indicates you are aware of the collection and storage of Protected Health Information, especially treatment, payment, and other healthcare information. Additionally, you understand the use of information to be for the purpose of treatment, billing and collection procedures, and within the staff of Sharon M Dossett Consulting, LLC as detailed below. Consent is not required to maintain and share information for these purposes. These disclosures within the clinic for treatment, payment, and other purposes that are termed “routine” disclosures.

ROUTINE DISCLOSURES

1. Treatment: The need for information for Treatment includes, but is not limited to, calling to confirm appointments; contacting you with  information about services of interest; aiding in diagnosis, assessment, recommendations, and treatment planning; consultation between staff members at Sharon M Dossett Consulting, LLC as required by law, such as consultation between interns and supervisors or between licensed staff and clinical consultants;  coordination between providers who jointly provide services to you within Sharon M Dossett Consulting, LLC; and coordination with support staff who assist in  maintaining records and in billing. 

            2.   Payment: The need for information for payment includes, but is not limited to determining      

                   eligibility for coverage, billing, claims management, collection activities, claims status, 

                   authorizations for treatment, and utilization review, including transmission of treatment plans to 

                   the insurer and following the insurer’s procedures for authorization.   

            3.  Other Health Care Operations: The need for information for other operations includes, but is not 

                 limited to, medical, administrative, educational, legal, or vocational planning or services undertaken

                 on patient’s behalf; quality assessment and utilization review; medical reviews; auditing; coroner  

                 functions; business planning and administrative services; internal consultation between staff 

                 members such as to plan services in emergencies, defense of lawsuits and administrative hearings. 

Disclosures with Consent.  A separate consent form, known as Authorization for Disclosure, will be completed permitting exchange of information with a specific insurer/third-party payer or other persons. An Authorization for Disclosure is valid for 15 months and you may revoke it in writing before it expires. We will then stop disclosing information to the parties on that form except we cannot take back the disclosures we already made in reliance upon your original consent. A disclosure with your permission is termed a “non-routine” disclosure. Storage of records is for seven years from the conclusion of services. Disposal is by shredding.  This form has no expiration date unless revoked or amended. 

Disclosure of Protected Information Without Consent. Federal law (42 CFR Part 2, 45 CFR 160 & 164), State law (Chapter 51, HFS 35, HFS 75, HFS92, HFS94), and various other codes and ethical principles also require careful safeguarding of your information. We are required by law to keep detailed  records. But we will only disclose information about you to persons not associated with Sharon M Dossett Consulting, LLC under a few very limited circumstances: 

1. with your specific written permission (known as “non-routine” disclosure),
   
2. in response to certain court orders and judicial subpoenas,
   
3. in the case of child or elder abuse or neglect reports or in the case of the duty to report clients who may be dangerous to self or others,
   
4. in the case of confidential audits by governmental, public health, insurance and other oversight programs,
   
5. in emergency situations, such as sending a patient to the hospital or calling the  

                   paramedics, we will disclose the minimum information necessary to effectively help    

                   the patient receive appropriate treatment.

Private Psychotherapy Notes. Therapist-private psychotherapy notes are not part of the clinic file and will not be disclosed to any entity. For example, interns make detailed notes to discuss their work in supervision for learning purposes. Psychotherapy notes are destroyed at the discharge of the case or when they no longer are needed for supervisory or record-keeping purposes. 

Policies. Because you may request the privacy policies notice of providers, we have provided this document covering all the policies. We may change this notice and, when we do, updates will be located on our website:  https://sharonmdossett.com 

• Revocation: This consent may be revoked by written notice at any time except to the extent the provider of information has already acted upon it.
  
• Restriction: You may request a restriction on the information to be released and its use. The Sharon M Dossett Consulting, LLC Authorization for Disclosure of Confidential Information/Records can be used for this purpose. You may also restrict the use of information within Sharon M Dossett Consulting, LLC by submitting a written request which clearly states which information is restricted. Doing so or deciding not to sign this document may, however, lead Sharon M Dossett Consulting, LLC to determine that services cannot in good faith or ethically be provided. We do not have to agree to the restrictions upon internal use of protected information. 

• History of Disclosures: You may request a listing of the history of any “non-routine” disclosures we have made, that is, disclosures requiring the Authorization for Disclosure of Confidential Information/Records Form, going back six years. If you request this history, we will have 60 days to prepare it.  Sharon M Dossett Consulting reserves the right to charge for the cost of assembling the information.
  
• Follow-Up: When an AODA patient completes treatment or transfers, state law (HFS 75.03(19)) requires follow-up contact.
  
• Fees for Copying: You have a right to request, in writing, a paper copy of your record (other than psychotherapy notes). A uniform and reasonable fee may be charged for a copy of records, and its transmission, which fee may be reduced or waived in accordance with agency policy. Sharon M Dossett Consulting, LLC will have 21 days to respond to a request for records. 

• Amending Records: You have a right to inspect the record and usually, where you find errors, to amend the record (by making a written request for permission to make additions and amendments), although state and federal law provides a few restrictions on this right when restrictions are judged to be in your best interests. Note: we cannot amend information we did not create, such as records from another provider. Psychotherapy notes are not included in this right to amend records. 

                   Submit a written request to amend records and your reasons to Sharon M Dossett Consulting, 

                   LLC. If we restrict your access to information, you may ask us to have a consultant on our staff 

                   review the denial and you will receive a written explanation of the reason and your right to review 

                   our decision. You may also ask for a summary or explanation of the information, as long as you 

                   agree to the fee for that service. 

                   If you want to amend the file, we’ll let you know if the amended information is accepted and we’ll 

                   send the change with any copies of the file which go out when you ask us to disclose the file. If it’s 

                   not accepted, we’ll inform you, and you may offer your disagreement, which will become part of     

                   the record; and you can have Sharon M Dossett Consulting, LLC review the process.  

• Transport of Data: We may need to transport documents from a home visit or satellite office, and we will do so with care to protect your confidentiality. 

• Electronic Transmissions: When we send a fax or email, we attempt to be sure the receiver of the information is entitled to it per your release. We attempt to limit communications about you to secure web sites or secure email unless we have your permission to transmit via unsecured email, and then only to you. If you receive this form via email or website, we will make a paper copy available as well.
  
• Complaints: You may bring complaints without retaliation to Sharon M. Dossett, MBA, MSW, LCSW, Principal Consultant, Sharon M Dossett Consulting, LLC, 11203 N. Buntrock Ave, Ste 201, Mequon, WI. 53092-1857, 414.367.6536.
  

The Secretary of the U.S. Dept. of Health and Human Services also receives complaints about believed privacy violations. The HHS Office For Civil Rights (OCR) is responsible for enforcement and is supposed to help providers and others comply with the rule.  Their informative website is found at http://www.hhs.gov/ocr/hipaa. 

This authorization form is intended to be in conformance with Section 51.30(4)(d), Wisconsin Statues, and Sections HFS 92.03(3)(d), 92.05, and 92.06., Wisconsin Administrative codes, and sections 49.53, 51.30(2), and 146.82 Wisconsin Statutes, and 42 CFR Part 2 and 45 CFR 160 and 164 of Federal Regulations.