HIPPA

ROBERT M. NEWELL, PH.D.

FORENSIC AND CLINICAL PSYCHOLOGY

Specializing in Behavioral Healthcare for Children &

Adolescents, Families, Couples, and Adults.

HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The privacy of your mental health information and/or the mental health information of your child is critically important to me. I understand that mental health information is personal, and I am committed to protecting it. I create a record of the treatment you and/or your child receive at my office. I maintain this record to provide you with quality care and to comply with certain legal requirements. This Notice will tell you about the ways I may use and share mental health information about you. I also describe your rights and certain duties I have regarding the use and disclosure of protected mental health information. This Notice is posted on my website at www.drrobertnewell.com

USE AND DISCLOSURE OF YOUR PROTECTED MENTAL HEALTH INFORMATION

The following section describes different ways that I may use and disclose protected mental health information. Not every use and disclosure will be listed. However, I have listed all the different ways I am permitted to use and disclose mental health information. I will not use or disclose your mental health information for any purpose not listed below without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to me.

Treatment: I obtain treatment information about you and/or your child and record it in a health record.

Payment: I may submit requests for payment to your health insurance company. The health insurance company requests certain information from me regarding medical care given. I will provide the required information to them about you and the care given so that you may access your mental health insurance benefit.

Health Care Operations: I obtain services from other business associates such as billing, accounting and legal services. I will share certain information about you with other business associates as necessary to obtain these services I require to serve you.

OTHER DISCLOSURES AND USES REQUIRED OR PERMITTED BY LAW

Under federal and/or Washington State law, I may disclose protected mental health information without your authorization under the following conditions and in the following situations:

Abuse & Neglect. I am a mandated reported under Washington State law, and am required to report suspected abuse and neglect of children, the elderly, and persons with disabilities.

Judicial/Administrative Proceedings. I may disclose your protected mental health information in the course of any judicial or administrative proceeding as allowed or required by law, with your specific written consent, or as directed by an order of the Court. To avert a life-threatening situation, I may disclose your protected mental health information consistent with applicable law to prevent an imminent threat to the health or safety of a person or the public.

Law Enforcement. I may disclose your protected mental health information for law enforcement purposes as required by law, such as when required by an order of the Court. I do not routinely release protected mental health information in response to an attorney’s subpoena.

Notification. In the event of an emergency, hospitalization, and with your permission, I may use or disclose your protected mental health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition.

Workers Compensation. If you are seeking compensation through Workers Compensation, I may disclose your protected mental health information to the extent necessary to comply with laws relating to Workers Compensation.

Other Uses. Other uses and disclosures besides those identified in the Notice will be made only as otherwise authorized by law or with your specific written authorization and you may revoke the authorization as previously provided.

The mental health and billing files I maintain are my physical property and are owned by me. However, the information contained in your file belongs to you. You have a right to:

Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to my office. I am not required to grant the request, but I will carefully review any request received.

Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information by making a written request to my office.

Request that you be allowed to inspect and copy your mental health record and billing record. You may exercise this right by delivering the request in writing to my office using a form I provide to you upon your written request. Payment of $1.00 per page will be charged for reproducing your mental health record. If you are a parent or a legal guardian of a minor, please note that certain portions of the minor’s mental health record may not be accessible to you. In those situations where I determine that access to your record would be harmful, I will restrict your access to the record in accordance with Washington State law. Accounting requests may not be made for periods of time going back more than six (6) years. I will provide the first accounting you request during any 12-month period without charge.

Appeal a denial of access to your protected health information except in certain circumstances. I will conduct the appeal and review the nature and purpose of the written request and determine whether the disclosure of certain information contained in your mental health record may be deleterious to your condition or impede further treatment of your condition. This decision will be binding.

Request that your mental health care record be amended to correct incomplete or incorrect information by delivering a written request to my office. (I am not required to make such amendments).

File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information.

Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, or payment, or disclosures made to you at your request.

Request that communication of your health information be made by alternative means or alternative location by delivering the request in writing to our office.

Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to my office.

You have the right to review the Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment and health care operations purposes.

If you want to exercise any of the above rights, please contact me at 509-910-0329, 1701 Creekside Loop, Suite 106, Yakima, Washington 98902 by telephone or in writing during normal business hours. I will provide you with assistance on the steps to take to exercise your rights.

MY DUTIES AND RESPONSIBILITIES

I am required to:

Maintain the privacy of your health information as required by law;

Provide you with a notice as to my duties and my privacy practices regarding the information I collect and maintain about you and/or your child;

Abide by the terms of this Notice;

Notify you if I cannot accommodate a requested restriction or request;

Accommodate your reasonable requests regarding methods to communicate health information with you.

I reserve the right to amend, change, or eliminate provisions in my privacy practices and access practices and to enact new provisions regarding the protected health information I maintain. If my information practices change, I will amend my Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy, by visiting my office to pick up a copy, or by visiting my website.

TO REQUEST INFORMATION OR FILE A COMPLAINT

Please contact me in writing if you have questions, would like additional information, or want to report a problem regarding the handling of your information. Also, if you believe your privacy rights have been violated, you may file a written complaint at my office by delivering the written complaint to me. You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. I will not retaliate against you if you file a complaint. I cannot, and will not require you to waive the right to file a complaint with the Department of Health as a condition of receiving treatment from the office.

DR. ROBERT M. NEWELL

Telephone: 509-910-0329

Email: mail@drrobertnewell.com

Website: www.drrobertnewell.com