NOTICE OF PRIVACY POLICIES AND PRACTICES
NOTICE OF PRIVACY POLICIES AND PRACTICES 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. Dr. Kotulski 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” is when Dr. Kotulski provides, coordinates, or manages your health care and other services related to your health care. For example, when Dr. Kotulski consults with another health care providers, such as your family physician or another psychologist.
“Payment” is when Dr. Kotulski obtains reimbursement for your healthcare.
“Health Care Operations” are activities that relate to the performance and operation of Dr. Kotulski’s practice. Examples are quality assessment activities, business related matters such as audits and administrative services, and case management and care coordination.
“Use” applies only to activities within Dr. Kotulski’s office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of Dr. Kotulski’s office, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
Dr. Kotulski 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 that permits only specific disclosures. In those instances when Dr. Kotulski is asked for information for purposes outside treatment, payment and health care operations, Dr. Kotulski will obtain an authorization from you before releasing information. Dr. Kotulski will also obtain an authorization from you before using or disclosing PHI in a way that is not described in this Notice. You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) Dr. Kotulsu has acted on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
Dr. Kotulski may use or disclose PHI without your consent or authorization in the following circumstances:
• Child Abuse: If information is given which leads Dr. Kotulski to suspect child abuse, neglect, or death due to maltreatment, Dr. Kotulski must report such information to the county Department of Social Services. If asked by the Director of Social Services to turn over information from your records relevant to a child protective services investigation, Dr. Kotulski must do so.
• Adult and Domestic Abuse: If Dr. Kotulski believes there is reaonable cause to believe that a disabled adult is in need of protective services, Dr. Kotulski must report this to the Director of Social Services.
• Health Oversight: The North Carolina Psychology Board and the California Board of Psychology has the power, when necessary, to subpoena relevant records should Dr. Kotulski be the focus of an inquiry.
• Serious Threat to Health or Safety: Dr. Kotulski may disclose your confidential information to protect you or others from a serious threat of harm by you.
• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that Dr. Kotulski has provided you and/or the records thereof, such information is privileged under state law, Dr. Kotulski must NOT release your information without 1) your written authorization or the authorization of your attorney or personal representative; 2) a court order; or 3) a subpoena duces tecum (a subpoena to produce records) where the party seeking your records provides me with a showing that you or your attorney have been served with a copy of the subpoena, affidavit and the appropriate notice, and you have not notified me that you are bringing a motion in the court to quash (block) or modify the subpoena. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. Dr. Kotulski will inform you in advance if this is the case.
• Worker’s Compensation: Dr. Kotulski does not do worker’s comp claims.
• Other Reasons: This includes when the use and disclosure without your consent or authorization is allowed under other sections of the Privacy Rule as well as Oregon, Washington and California’s confidentiality laws. This also 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 DFA- regulated products or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
There may be additional disclosures of PHI that Dr. Kotulski is required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common.
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 about you. However, Dr. Kotulski is 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.
• Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in your clinician’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Dr. Kotulski may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, Dr. Kotulski 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. Dr. Kotulski may deny your request. Upon your request, Dr. Kotulski 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 for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, Dr. Kotulski 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 this notice from Dr. Kotulski upon request, even if you have agreed to receive the notice electronically.
• 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 Dr. Kotulski’s 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) Dr. Kotulski’s risk assessment fails to determine that there is a low probability that your PHI has been compromised.
Psychologist’s Duties:
• Dr. Kotulski is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.
• Dr. Kotulski reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, I am required to abide by the terms currently in effect.
• If Dr. Kotulski revises these policies and procedures, she will provide you with a revised notice at your next scheduled appointment or upon your request. This notice will be posted in her office and on her website.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision Dr. Kotulski makes about access to your records, or have other concerns about your privacy rights, you may discuss this further with her at any time. Contact Dr. Kotulski at 626-200-4375.
If you believe that your privacy rights have been violated and wish to file a complaint with Dr. Kotulski, you may send your written complaint to her email at [email protected]. You may also send a written complaint to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue S.W. Washington, D.C. 20201.
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
This notice went into effect April 14, 2003. This notice was revised on February 18, 2024.