Hawaii Notice Form (Confidentiality in Legalese)
Confidentiality (And Then Some) In Plain English
Your Authorization For Me To Release Information About You
When Your Authorization Is Not Required
In the old days, when life was simpler, whatever you told a therapist about yourself was confidential and could not be revealed to anyone else (with a few exceptions.) No one worried much about confidentiality.
Things changed with the arrival of managed care and computers. Doctors and other health care providers had to give the managed care company ongoing, detailed information about your problem and your progress in order for your treatment to be approved. Once such personal and often embarrassing information was entered into a computer database, neither you nor your health care provider had control over who read it or what was done with it.
Concern over this led to the passage of a federal law called, the
Insurance Portability and Accountability Act," or "HIPAA." Among other
this law assures you of certain protections about your health
records. As a psychologist, I'm required to publish on my website the
"Notice to Consumers," also called the "Hawaii Notice Form." Here it
is, first in its original legalese, and then translated (by me) into
You do need to understand it, because, during your first session with me, you will be signing a form that says you have read it, either on this website or on a hard copy.
HAWAII NOTICE FORM
Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information
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, Nada Mangialetti, Ph.D. 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"
- 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 relate 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, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· "Disclosure" applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I, Nada Mangialetti, Ph.D., 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 I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy Notes. "Psychotherapy Notes" are 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 Psychotherapy 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.
III. Uses and Disclosures with Neither Consent nor Authorization
I, Nada Mangialetti, Ph.D., may use or disclose PHI without your consent or authorization in the following circumstances:
· Child Abuse - If I have reason to believe that child abuse or neglect has occurred or that there exists a substantial risk that child abuse or neglect may occur in the reasonably foreseeable future, I must immediately report the matter to the appropriate authority.
· Adult and Domestic Abuse - If I, in the performance of their professional or official duties, know or have reason to believe that a dependent adult has been abused and is threatened with imminent abuse, I must promptly report the matter to the appropriate authority.
· Health Oversight Activities - If the Hawaii Board of Psychology is investigating my competency, license or practice, I may be required to disclose protected health information regarding you.
Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made for information about the counseling or psychotherapy services provided to you and/or the records thereof, such information is privileged under Hawaii law, and I shall 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. I shall inform you in advance if this is the case.
· Serious Threat to Health or Safety - I may disclose protected health information regarding you where there is clear and imminent danger to you or another individual or to society, and then only to appropriate professional workers or public authorities. If you are at risk, I may also contact family members or others who could assist in providing protection.
· Worker's Compensation - If you have filed a worker's compensation claim, I may be required to disclose PHI about any services I have provided to you that are relevant to the claimed injury.
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. (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 an 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 notice from me upon request, even if you have agreed to receive the notice electronically.
· 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.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me, Nada Mangialetti, Ph.D., Licensed Clinical Psychologist, at (808) 292-1440.
If you believe that your privacy rights have been violated and wish to file a complaint with me office, you may send your written complaint to me at 91-110 Hanua Street, Suite 208-A, Kapolei, Hawaii 96707.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I will 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.
This notice will go into effect on April 15, 2003.
Confidentiality (And Then Some) In Plain English
"protected health information" or "PHI" consists of two parts: (A) your
"clinical record" (also called your "medical record"), and, (B) my
psychotherapy notes (also called "progress notes" or "process notes.")
(A)Your clinical/medical record includes:
reasons for seeking
how your problem impacts your life phone contact records
diagnosis email correspondence
treatment goals and progress toward them other reports
medical history test records
social history questionnaires
treatment history professional consultation reports
past treatment records from other therapists
(B)My psychotherapy/progress/process notes are not considered part of your clinical/medical record. These
notes that I make for myself after each session, so that I can remember
we talked about and what we did. My notes include a
section on what
you told me, a section on what I observed about you, a section on
professional assessment of your condition at that time, and a section
what you and I plan to do to help you further. Unlike most
psychologists, I record my notes in MP3 audio format; I do not
keep written notes. These notes are kept separate
from your clinical/medical record, on a hard drive, and are later
archived on a CD. They are detailed and personal, so I wouldn't
recommend sharing them with anyone.
Your Authorization For Me To Release Information About You
With certain exceptions, which are explained below, your
clinical/medical record cannot be revealed to anyone else, without your
written consent. There may be a copying charge. Your may reveiw your
clinical/medical record with me or another mental health professional. If you want
me to share information about your problem
or progress with someone else (for example, another psychotherapist,
your physician, your attorney, a relative, etc.),
I'll be glad to do so, after you sign an "Authorization For The Release
Of Confidential Information." This form will state exactly what
information is to be released, and will have an expiration date.
When YourAuthorization Is Not Required
This section is really important. It is about the exceptions to the general rule of confidentiality. Read it, and see which ones may apply to you.
1. If I believe that you intend to harm yourself
or someone else, I'm obligated, by law, to tell whomever I need to tell
to stop that from happening. I may call 911, or a family member or a
friend, if this would protect you or someone else from harm. Our
society values the preservation of LIFE above confidentiality!
2. If I believe that you're either the victim or
the perpetrator of child abuse or elder abuse, I'm obligated, by law,
to notify the authorities.
3. You will probably be using your medical insurance to
pay for your psychotherapy sessions. Your insurance company will
require a diagnosis from me. They may also require me to fill out a
questionnaire about you. If you're under "managed care" or an "HMO",
they may require more detailed information about your condition and a
treatment plan before they will authorize payment for treatment. They
may require periodic updates about your progress in order to cover
4. If you're receiving welfare support (not just food
stamps), the welfare department requires periodic reports from me about
your attendance. In Hawaii, you are usually required to attend a
minimum of two psychotherapy sessions per month in order to be
considered "in compliance."
5. If your therapy is court-ordered, the court will
probably demand a report about your attendance, compliance and
6. Even if your therapy is not court-ordered, a court of law (that is, a judge) can subpoena my records. I am not legally obligated to obey an attorney's subpoena; that would require your written authorization. But I must obey a judge's subpoena.
7. If you've filed a worker's compensation claim, I may be required to disclose information relevant to your injury.
8. I may consult one or more colleagues for
professional advice to help me help you better, but I won't reveal your
identity. I will note all such consultations in your clinical record.
If you're under 18,your parents or legal guardian may ask about you. I will not automatically report to them without your knowledge, but if they're giving you consent to see me and they're paying for it, they do have a legal right to be kept informed. I will respect your desire to keep certain information just between you and me, as long as it doesn't involve harm to yourself or others, drug or alcohol use, or certain other dangerous or risky behaviors that any parent would want to know about. If that's the case, or if your parents ask about you, I'll let you know first, coach you on how to break the news to your parents, and then schedule a joint session between you and your parents. I'll help you and your parents feel more comfortable discussing things with each other directly. I won't just go behind your back and "tattle" on you. (If I did that, you probably would never tell me or any other therapist anything again!)
Nada Mangialetti, Ph.D.
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