LUZIO & ASSOCIATES BEHAVIORAL SERVICES, INC.
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.

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

I may use and disclose your protected health information (PHI), for treatment, payment and health care operations purposes. 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”
- 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 of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
-Health Care Operations are activities that related to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

“Use” applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

“Disclosure” applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties, via electronically, mail, fax, or phone.

I may also use and disclose your PHI to contact you as a reminder that you have an appointment, that you should schedule an appointment or to tell you about possible treatment options or alternatives, health related benefits or other services that may be of interest to you.

II. Uses and Disclosures with Neither Consent nor Authorization

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

Child Abuse – If I believe that a child is a victim of child abuse or neglect, I must report this belief to the appropriate authorities.

Adult and Domestic Abuse – If I believe or have reason to believe that an individual is an endangered adult, I must report this belief to the appropriate authorities.

Health Oversight Activities – If the Indiana Attorney General’s Office requests information regarding my practices, then I may be required to disclose PHI to such office.

Judicial and Administrative Proceedings – If the patient is involved in a court proceeding and a request is made for information about the professional services I provided you and/or the records thereof, such information is privileged under state law, and I will not release information without the written authorization of you or your 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. You will be informed in advance if this is the case.

Serious Threat to Health or Safety – If you communicate to me an actual threat of violence to cause serious injury or death against a reasonably identifiable victim or victims or if you evidence conduct or make statements indicating an imminent danger that you will use physical violence or use other means to cause serious personal injury or death to others, I may take the appropriate steps to prevent that harm from occurring. If I have reason to believe that you present an imminent, serious risk of physical harm or death to yourself, I may need to disclose information in order to protect you. In both cases, I will only disclose what I feel is the minimum amount of information necessary.

Worker’s Compensation – I may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work related injuries or illness without regard to fault.

Required by Law – I may disclose PHI about you when I am required to do so by federal, state or local law.

Coroners, Medical Examiners and Funeral Directors – I may release your PHI to a coroner, medical examiner and/or funeral director to assist such individual in the performance of his or her duties.

III. Other Uses and Disclosures Requiring Authorization

I am required to obtain written authorization from you for any uses and disclosures of PHI other than those described above. I will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychology Notes” or notes I have made about our conversation during a private group, joint, or family counseling session, which I have 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 Psychology Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have 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.

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, I am not required to agree to a restriction to your 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 seeing me. On your request, I will send your bills to another address).

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. On your request, I will discuss with you the details of the request and denial process.

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. On your request, I will discuss with you the details of the amendment process.

Right to Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, I 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 the notices from me upon request, even if you have agreed to receive the notices electronically.

Provider Duties

I am required 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 regarding policies which I am bound by law to report changes to you, our office will provide you with notification of such changes.

V. Questions and Complaints

If you have questions about the notice, disagree with a decision I make about access to your records, or have concerns about your privacy rights, you may contact our Office Administrator, Lindi Bonesteel, at (812) 479-1916, info@luzioassociates.com, or by writing to her at 4411 Washington Avenue, Suite 300 Evansville, IN 47714.

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.

You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on April 2020.

I reserve the right to change the terms of the notice and to make the new notice provisions effective for all PHI that I maintain. My office will provide you with a revised notice if such notice is changed