Centering Your Life Psychology PLLC
Jonathan Kodet PhD LP
NOTICE OF PRIVACY PRACTICES
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.
Your privacy is important to me. I am required by federal and state law to take certain steps to protect your privacy and to tell you about these privacy practices. The type of health information that is protected by this document includes things such as: your name, address, date of birth, social security number, telephone number, and the specifics of your medical and psychological records (for example: diagnosis, treatment received, dates of service). I will take steps in all cases to disclose only the minimum and necessary information required. If I change these policies, I will notify you in writing, in person, or by mail. Unless I notify you of changes, I am required to follow these policies as described below.
Uses and Disclosures that Require Your Authorization
I may use your personal health information for the following purposes:
Treatment – This means that I may disclose information to another professional in the course of providing treatment to you. For example, I may consult with a physician, psychiatrist, or psychologist.
Payment – I may disclose information to an insurance company for reimbursement or to determine eligibility for services.
Health Care Operations – I may disclose information for audits, quality assurance, or other activities related to running my business (e.g., using a billing service).
Appointment reminders/information – I may contact you to provide reminders of appointments or to provide information about treatment alternatives or other services that may be of interest to you.
You may allow me to share information for purposes other than treatment, payment, and health care operations. For example, you could give me permission to talk with a family member about the work you are doing in counseling. In order for this to happen, you must sign a form called an “Authorization for the Release of Confidential Information.” If you change your mind after you have signed an authorization, you can cancel the release, unless there are reasons that prevent you from doing so. For example, a court or insurance company may require you to allow the release of information.
I will also obtain an authorization from you before using or disclosing the following protected health information (PHI):
· PHI in a way that is not described in this Notice.
· Psychotherapy notes
· PHI for marketing purposes
Uses and Disclosures Without Your Authorization
There are some circumstances when I may be required or allowed to release personal information without your permission. In these cases, I will make every attempt to release the minimum amount of information necessary. The following describes the some of the types of situations in which I may have to release information:
Child abuse: If I know or suspect that a child is being abused or neglected, or has been abused or neglected in the last three years, I am required to report this information to county child protection services and/or the police.
Abuse of vulnerable adult: If I know or suspect that a vulnerable adult is being abused, I must report this to adult protective services and/or the police.
Serious Threat to Health or Safety: If you make a specific and serious threat of physical harm to yourself or someone else, I am required to take steps to protect you and any other identifiable people. This may include contacting family members, law enforcement, and/or any identified potential victims.
Judicial and Administrative Proceedings: If you are involved in a court case, the records of our work together could be requested through a court order.
Substance Use by Pregnant Women: Use of controlled substances (cocaine, heroin,
methamphetamine, amphetamine, phencyclidine or their derivatives) by a woman who is pregnant.
Deceased Clients: The parents or spouse of a deceased client has the right to access the client’s file.
Health Oversight Activities: This includes audits, criminal investigations, or investigations by a professional licensing board. For example, the Minnesota Board of Psychology could subpoena records from me if they are investigating my practice.
Medical Emergency: I may use or share your personal information to help you in the case of a medical emergency.
Law Enforcement: I may share personal information with law enforcement if you commit a crime against my business or me.
When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or
for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
Your Rights
Access: You have the right to see and receive a copy of your health records. There are limited instances in which I may not grant your request. If this were to be the case, I would notify you of this in writing and give you information about your rights to request a review of my denial.
Amendment: You have the right to request that I amend (change) your health information as provided by federal law. These requests must be in writing. I am not required to agree to the requested amendment. If I agree to your request, I cannot physically remove the information; I can add an amendment to the file. If I do not agree to your request, you may have a statement in your file that states your disagreement with my records.
List of Disclosures: You have the right to a list of all disclosures that I make about your health information.
Receiving Confidential Communications: You have the right to receive confidential
information in alternative methods and/or locations. For example, you may request that I send information to an address other than your home address; or, you may request that I only call your cell phone and not your home/work phone.
Right to a copy of this Notice: You have the right to receive your own copy of this privacy notice.
Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket. You have
the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.
Right to Be Notified if There is a Breach of Your Unsecured PHI. You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the
HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.
For more information/Complaints I am the compliance officer for my practice. I will respond to any questions or requests for information you have through my Contact form on my website at www.centeringyourlife.com. If you are concerned that I may have violated your confidentiality rights as outlined above, or if you would like more information about your rights, you may contact:
Office for Civil Rights
U.S. Department of Health & Human Services
233 N. Michigan Ave. - Suite 240
Chicago, IL 60601
(312) 886-2359; (312) 353-5693 (TDD)
(312) 886-1807 FAX
Effective Date
This notice is effective as of 1/17/2022
Jonathan Kodet PhD LP
NOTICE OF PRIVACY PRACTICES
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.
Your privacy is important to me. I am required by federal and state law to take certain steps to protect your privacy and to tell you about these privacy practices. The type of health information that is protected by this document includes things such as: your name, address, date of birth, social security number, telephone number, and the specifics of your medical and psychological records (for example: diagnosis, treatment received, dates of service). I will take steps in all cases to disclose only the minimum and necessary information required. If I change these policies, I will notify you in writing, in person, or by mail. Unless I notify you of changes, I am required to follow these policies as described below.
Uses and Disclosures that Require Your Authorization
I may use your personal health information for the following purposes:
Treatment – This means that I may disclose information to another professional in the course of providing treatment to you. For example, I may consult with a physician, psychiatrist, or psychologist.
Payment – I may disclose information to an insurance company for reimbursement or to determine eligibility for services.
Health Care Operations – I may disclose information for audits, quality assurance, or other activities related to running my business (e.g., using a billing service).
Appointment reminders/information – I may contact you to provide reminders of appointments or to provide information about treatment alternatives or other services that may be of interest to you.
You may allow me to share information for purposes other than treatment, payment, and health care operations. For example, you could give me permission to talk with a family member about the work you are doing in counseling. In order for this to happen, you must sign a form called an “Authorization for the Release of Confidential Information.” If you change your mind after you have signed an authorization, you can cancel the release, unless there are reasons that prevent you from doing so. For example, a court or insurance company may require you to allow the release of information.
I will also obtain an authorization from you before using or disclosing the following protected health information (PHI):
· PHI in a way that is not described in this Notice.
· Psychotherapy notes
· PHI for marketing purposes
Uses and Disclosures Without Your Authorization
There are some circumstances when I may be required or allowed to release personal information without your permission. In these cases, I will make every attempt to release the minimum amount of information necessary. The following describes the some of the types of situations in which I may have to release information:
Child abuse: If I know or suspect that a child is being abused or neglected, or has been abused or neglected in the last three years, I am required to report this information to county child protection services and/or the police.
Abuse of vulnerable adult: If I know or suspect that a vulnerable adult is being abused, I must report this to adult protective services and/or the police.
Serious Threat to Health or Safety: If you make a specific and serious threat of physical harm to yourself or someone else, I am required to take steps to protect you and any other identifiable people. This may include contacting family members, law enforcement, and/or any identified potential victims.
Judicial and Administrative Proceedings: If you are involved in a court case, the records of our work together could be requested through a court order.
Substance Use by Pregnant Women: Use of controlled substances (cocaine, heroin,
methamphetamine, amphetamine, phencyclidine or their derivatives) by a woman who is pregnant.
Deceased Clients: The parents or spouse of a deceased client has the right to access the client’s file.
Health Oversight Activities: This includes audits, criminal investigations, or investigations by a professional licensing board. For example, the Minnesota Board of Psychology could subpoena records from me if they are investigating my practice.
Medical Emergency: I may use or share your personal information to help you in the case of a medical emergency.
Law Enforcement: I may share personal information with law enforcement if you commit a crime against my business or me.
When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or
for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
Your Rights
Access: You have the right to see and receive a copy of your health records. There are limited instances in which I may not grant your request. If this were to be the case, I would notify you of this in writing and give you information about your rights to request a review of my denial.
Amendment: You have the right to request that I amend (change) your health information as provided by federal law. These requests must be in writing. I am not required to agree to the requested amendment. If I agree to your request, I cannot physically remove the information; I can add an amendment to the file. If I do not agree to your request, you may have a statement in your file that states your disagreement with my records.
List of Disclosures: You have the right to a list of all disclosures that I make about your health information.
Receiving Confidential Communications: You have the right to receive confidential
information in alternative methods and/or locations. For example, you may request that I send information to an address other than your home address; or, you may request that I only call your cell phone and not your home/work phone.
Right to a copy of this Notice: You have the right to receive your own copy of this privacy notice.
Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket. You have
the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.
Right to Be Notified if There is a Breach of Your Unsecured PHI. You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the
HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.
For more information/Complaints I am the compliance officer for my practice. I will respond to any questions or requests for information you have through my Contact form on my website at www.centeringyourlife.com. If you are concerned that I may have violated your confidentiality rights as outlined above, or if you would like more information about your rights, you may contact:
Office for Civil Rights
U.S. Department of Health & Human Services
233 N. Michigan Ave. - Suite 240
Chicago, IL 60601
(312) 886-2359; (312) 353-5693 (TDD)
(312) 886-1807 FAX
Effective Date
This notice is effective as of 1/17/2022
