South Carolina Notice Form
Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information
Effective Date: 02/22/2024
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 IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
I 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:
Protected Health Information (PHI) refers to information in your health record that could identify you.
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 include when I disclose your PHI to your health insurer to obtain reimbursement or to determine eligibility or coverage.
Health Care Operations are activities that relate to the performance and operation of my practice, such as quality assessment and improvement activities, business-related tasks such as audits, case management, coordination, and utilization analysis.
Disclosures are the release, transfer, or providing of access to information about you to parties outside my practice.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An authorization is written permission above and beyond the general consent. In those instances where I am asked for information and an authorization is required, I will contact you for that authorization. I will also need to obtain an authorization if therapy notes are requested. I have conversations in a private, joint, or family counseling setting, which are kept separately and given a greater degree of protection. You may revoke all such authorizations at any time, provided each revocation is in writing, to the extent that I have not taken action in reliance on the authorization.
III. Uses and Disclosures with Neither Consent nor Authorization
Child Abuse: When a professional has reasonable cause to believe that a child’s physical or mental health or welfare has been or may be adversely affected by abuse or neglect, reporting is required by law.
Adult and Domestic Violence: When abuse of an adult is likely confirmed or when a domestic violence situation exists, I am required to report this within 24 hours or the next working day to the appropriate program or personnel.
Health Oversight: The South Carolina Board of Examiners in Psychology has the power, when necessary, to subpoena records and submit them for their investigation.
Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services I have provided you, such information is privileged under state law and I will not release information without the written authorization of you or your personal or legal 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.
Serious Threat to Health or Safety: When I communicate a serious threat to yourself or others, I may, consistent with applicable law and standards of ethical conduct, disclose PHI if I believe in good faith that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
IV. Patient’s Rights and Psychologist’s Duties
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am 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. I will accommodate reasonable requests.
Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) 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.
Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request.
Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization.
Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
V. 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 terms currently in effect. If I revise my policies and procedures, I will notify you by mail.
VI. 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 directly. You may also send a written complaint to the U.S. Department of Health and Human Services. I will provide you with the address upon request. There will be no retaliation for filing a complaint with either the Department of Health and Human Services or with me.
Contact Information
Bonnie F. Cleaveland, PhD, ABPP
PO Box 31088, Charleston, SC 29417
Phone: 843-571-4005
Email: bonnie@bonniecleaveland.com