Notice of Psychologist’s Policies and Practices to

Protect the Privacy of Your Patient’s Health Information



I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

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

  • PHI” refers to information in your health record that could identify you.
  • “Treatment, Payment, and Health Care Operations”
  • Use” applies only to activities within CABH, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  • Disclosure” applies to activities outside of CABH, such as releasing, transferring, or providing access to information about you to other parties.

1. Treatment: CABH may use and disclose PHI in order to provide treatment to you. For example, CABH may use PHI to diagnose and provide counseling service to you. We may also disclose your information to remind you of appointment times. We may disclose your information to any family members or significant others that you voluntarily decide to bring to and include in a therapy session. We may disclose your PHI, with the exception of identifying information, during professional clinical supervision and/or consultation, in order to ethically provide you the highest quality services

2. Payment: CABH may use or disclose PHI so that services you receive are appropriately billed and payment is collected. By way of example, it may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.

3. Health Care Operations: CABH may use and disclose PHI in connection with our health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities.

II. Uses and Disclosures Requiring Authorization

CABH may use or disclose PHI for purposes outside of treatment, payment, or 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 CABH is asked for information for purposes outside of treatment, payment or health care operations, CABH will obtain an authorization from you before releasing this information. CABH will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes your therapist has made about your conversations during private, group, joint, or family counseling sessions, which the therapist 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) CABH has 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

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

    • Child Abuse – If your therapist has reasonable cause to suspect that a child has been or may be subjected to abuse or neglect, or if your therapist observes a child being subjected to conditions that would reasonably result in abuse or neglect, the therapist must immediately report such information to the Missouri Division of Family Services. Your therapist must also report sexual abuse or molestation of a child under 18 years of age to Family Services. Your therapist may also report child abuse or neglect to a law enforcement agency or juvenile office.
    • Adult and Domestic Abuse – If your therapist has reasonable cause to suspect that an eligible adult presents a likelihood of suffering physical harm or is in need of protective services, your therapist 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 his or her own interests or adequately perform or obtain services which are necessary to meet his or her essential human needs.
    • Health Oversight Activities – The Missouri Attorney General’s Office may subpoena records from CABH 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 thereof, such information is privileged under state law, and CABH will not release information without written authorization from you or your personal or legally-appointed representative, 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. CABH will inform you in advance if this is the case.
    • Serious Threat to Health or Safety – When your therapist 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, CABH must disclose your relevant confidential information to the appropriate professional workers, public authorities, the potential victim, his or her family, or your family.
    • Workers' Compensation – If you file a worker’s compensation claim, CABH must permit your record to be copied by the 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, CABH is not required to agree to a restriction 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 receiving services at CABH. On your request, CABH will send your bills to another address.) All requests should be made in writing, a form can be provided for you for this purpose at your request.
    • Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in CABH mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. All requests for access must be made in writing. CABH may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, your therapist will discuss with you the details of the request and denial process. CABH may charge a fee for the costs of copying and sending you any records requested. If you are a parent or legal guardian of a minor, please note that certain portions of the minor’s medical record may not be accessible to you, in accordance with state law.
    • Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. CABH may deny your request. On your request, your therapist 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. This right applies to disclosures for purposes other than treatment, payment or health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations. On your request, your therapist 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 this notice from CABH upon request, even if you have agreed to receive the notice electronically.

Psychologist’s Duties:

    • CABH is required by law to maintain the privacy of PHI and to provide you with a notice of its legal duties and privacy practices with respect to PHI.
    • CABH reserves the right to change the privacy policies and practices described in this notice. Unless CABH notifies you of such changes, however, CABH is required to abide by the terms currently in effect.
    • If CABH revises its policies and procedures, CABH will provide you with a revised notice during your next scheduled appointment or by mail.

V. Complaints

If you are concerned that CABH has violated your privacy rights, or you disagree with a decision made about access to your records, you may contact the Privacy Officer, Catherine B. Hasler, Ph.D., Director of CABH, at 314-569-5055 to discuss your concerns.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on January 1, 2017.

CABH reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that CABH maintains. If CABH makes a change to this notice, CABH will provide you with a revised notice during our next scheduled appointment or by mail.