I. Uses and Disclosure For Treatment, Payment, And Health Care Operations

I 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. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process my health care claims.

  • 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. Certain Uses And Disclosures Require Your Authorization.

I may use or disclose your 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. For example, certain information that may be contained in your medical record is considered by state and/or federal law to be highly confidential including, for example, HIV testing or test results, psychotherapy notes, and genetic information. Therefore, this type of information gets additional protection from disclosure and at all times requires a written authorization.

In particular, I will not use or disclose notes that I take (if any) during our therapy sessions (“psychotherapy notes”) without your prior written authorization except for the following: 1) use by the originator of the notes for your treatment, 2) for training staff, students, and other trainees, 3) to defend myself if you sue me or bring some other legal proceeding, 4) if the law requires me to disclose the information to you or the Secretary of HHS or for some other reason, 5) in response to health oversight activities involving me, 6) to avert a serious and imminent threat to health or safety, or 7) to the coroner or mental health examiner if you should pass away. To the extent that you revoke an authorization to use or disclose your psychotherapy notes, we will stop using or disclosing these notes. You may revoke all such authorizations at any time, provided each revocation is in writing (or orally in limited cases). You may not revoke an authorization to the extent that I have already acted upon your previously provided authorization.

III. Certain Uses and Disclosures Do Not Require Your Authorization

I may, and am sometimes required by law, to use or disclose PHI without your consent or authorization. Such circumstances may include:

1. Child Abuse. If I, in my professional capacity, have reasonable cause to believe that a minor child is suffering physical or emotional injury resulting from abuse inflicted upon her/him which causes harm or substantial risk of harm to the child’s health or welfare (including sexual abuse), or neglect, including malnutrition, I must immediately report such condition to the Massachusetts Department of Social Services.

2. Adult and Domestic Abuse. If I have reasonable cause to believe that an elderly person (age 60 or older) is suffering from or has died as a result of abuse, I must immediately make a report to the Massachusetts Department of Elder Affairs.

3. Health Oversight Activities. If the Massachusetts Board of Examiners of Psychologists is investigating my practice, the board may subpoena records relevant to such investigation.

4. Judicial and Administrative Proceedings. If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information without the written authorization form 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.

5. Serious Threat to Health or Safety. If I believe in good faith that there is a risk of imminent personal injury to you or to other individuals or risk of imminent injury to the property of other individuals, I may disclose the appropriate information as permitted by law. I may disclose information about you to family members or other persons close to you in an emergency situation, but I will use my best judgment to only share information that others really need to know and take reasonable precautions. Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization. I must also do so if I know you have a history of physical violence and I believe there is a clear and present danger that you will attempt to kill or inflict bodily injury upon an identified person. Furthermore, if you present a clear and present danger to yourself and refuse to accept further treatment, and I have a reasonable basis to believe that you can be committed to a hospital, I must seek said commitment and may contact members of your family or other individuals if it would assist in protecting you.

6. 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.

7. Public Health. I may, and am sometimes required by law, to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When I report suspected elder or dependent adult abuse or domestic violence, I will inform you or your personal representative promptly unless in my best professional judgment, I believe the notification would place you at risk of serious harm or would require informing a personal representative I believe is responsible for the abuse or harm.

8. Death. If you pass away, I am allowed to share relevant PHI with your family under the same circumstances that such disclosures were permitted when you were alive and receiving treatment from me.

IV. You Have The Following Rights With Respect To Your PHI

1. 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, unless you pay for a health care product or service in full (out of pocket), in which case you may request that I not share health information pertaining only to that product or service with your health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment). If I agree to your request, I must put the restriction in writing and abide by it except if you need to be treated in an emergency. You may not ask me to restrict uses and sharing of information that I am legally required to make.

2. 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. When you give me an address and telephone number by which to reach you, it is your responsibility to give ones to me that will allow me to contact you, provide care to you, and receive payment for my services in a confidential manner. If you wish to communicate by email, I will send communications securely/encrypted unless you give consent for me to send them without encryption. In this case, you must be aware that there is a risk that information will be breached given that I do not have control over the security of your or my email carrier.

3. Right to Inspect and Copy – You have the right to inspect or obtain a written or electronic 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. You must ask for this in writing. If you ask for an electronic copy, I will work with you to provide you with an electronic form of your choice, if it is readily available. On your request, I will discuss with you the details of the request and denial process. You will be charged a fee for the request. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. If your request is denied, I will explain the reasons in writing and tell you which rights you have, if any, to a review of the denial. I may offer to give you a summary or explanation of the information you requested as long as you agree in advance to this and to any fees it might cost.

4. Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. You must make your request in writing and give reasons for why you want the change. On your request, I will discuss with you the details of the amendment process. I may deny your request.

5. 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, I will discuss with you the details of the accounting process.

6. 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.

V. PSYCHOLOGIST’S DUTIES

1. 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. Your PHI may be kept in either paper or electronic form. Information such as your symptoms, diagnoses, treatment, care plan, and demographic and payment information are examples of your health information that may be collected and stored in your health record. Information about care you have received from other providers may also be included in your health record.

2. I am required by law to maintain mental health records for at least seven years after the last day of service (or for a minor client, either seven years after the last day of service or until the client reaches the age of 18, whichever is longer), and other medical records in accordance with state and federal regulations. If a breach occurs, I am required to notify you unless a risk analysis shows there to be a low probability of PHI compromise.

3. I will only recommend products to you (such as self-help books, etc) that are in your best interest and that I will not receive any sort of financial compensation for.

4. 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.

5. If I revise these privacy policies and practices, I will notify you in person or by mail. You have a right to request a copy of the revised Notice of Privacy Practices at any time.

VI. 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 in writing via email (contact@mindsightservices.com).

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services by sending a letter to 200 Independence Avenue, S.W. Washington, D.C. 20201 or calling 1-877-696-6775. You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

VII. EFFECTIVE DATE OF THIS NOTICE

This notice will go in effect on February 17, 2021.

Dr. Komal Gupta reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. Dr. Komal Gupta will provide you with a revised notice if these policies are changed.