Jonathan Speare

Speare Psychological Services

Jonathan Speare, Ph.D.

Licensed Psychologist

Confidentiality

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This page is being revised to comply with the State of Minnesota and Federal HIPAA regulations.

NOTICE OF PRIVACY PRACTICES

Speare Psychological Services, P.A.
Jonathan Speare, Ph.D., Licensed Psychologist
225 1st St. N., Suite 3100
Virginia, MN 55792
218-741-3740
Jonathan Speare, Ph.D., Licensed Psychologist, Owner and Privacy Officer

Effective Date: September 23, 2013

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Speare Psychological Services, P.A. understands the importance of privacy and I, Jonathan Speare, Ph.D., Licensed Psychologist, am committed to maintaining the confidentiality of your personal health information. Speare Psychological Services. P.A. makes a record of the counseling services that Jonathan Speare, Ph.D., Licensed Psychologist provides and may receive such records from others. Speare Psychological Services may use these records to provide or enable other health care providers to provide quality care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this practice properly. Speare Psychological Services, P.A. is required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how Speare Psychological Services, P.A may use and disclose your personal health information. It also describes your rights and our legal obligations with respect to your personal health information. If you have any questions about this Notice, please contact our Privacy Officer listed above.

TABLE OF CONTENTS

  1. How This Practice May Use or Disclose Your Personal Health Information
  2. When This Practice May Not Use or Disclose Your Personal Health Information
  3. Your Personal Health Information Rights
    1. Right to Request Special Privacy Protections
    2. Right to Request Confidential Communications
    3. Right to Inspect and Copy
    4. Right to Amend or Supplement
    5. Right to an Accounting of Disclosures
    6. Right to a Paper or Electronic Copy of this Notice
    7. Right to Restrict Disclosures When You have Paid for Your Care Out-of-Pocket
    8. Right to Be Notified if There is a Breach of Your Unsecured Protected Health Information (PHI)
  4. Changes to this Notice of Privacy Practices
  5. Complaints

A. How This Practice May Use or Disclose Your Health Information

This practice collects health information about you and stores it in a paper chart that is in a locked cabinet when the office is closed and as of the date of this notice we do not have or use electronic health record/personal health record except to do the billing of the services provided. This is your record. The record is the property of this practice, but the information in the record belongs to you. The law permits us to use or disclose your health information for the following purposes:

  1. Treatment. Speare Psychological Services, P.A. may use personal health information about you to provide your care. Speare Psychological Services, P.A. may disclose PHI to our employees and others who are involved in providing the care you need. For example, Speare Psychological Services, P.A. may share your personal health information with other health care providers who will provide services that Jonathan Speare, Ph. D., Licensed Psychologist does not provide. Speare Psychological Services, Ph.D., Licensed Psychologist may also disclose personal health information to members of your family or others who can help you when you are sick or injured, or after you die.
  2. Payment. Speare Psychological Services, P.A. may use and disclose personal health information about you to obtain payment for the services Jonathan Speare, Ph.D., Licensed Psychologist provides. For example, Speare Psychological Services, P.A. may give your health plan the information it requires before it will pay us. Speare Psychological Services, P.A. may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you. If you fail to comply with your agreement for payment of services received, and Speare Psychological Services, P.A. has to use other legal means of obtaining your payment, certain identifying information will have to be turned over to those agencies.
  3. Collection on “delinquent” account balances. If your bill goes unpaid for an extended period of time (period of time decided by Jonathan Speare, Ph.D., Licensed Psychologist), Speare Psychological Services, P.A. may turn your account over to a collection agency or go to small claims court. If Speare Psychological Services, P.A. decides to do this, the practice would have to inform the collection agency or small claims court of your name, phone number(s), dates of service and any additional information necessary to get this account paid in full. This information provided to the collection agency or small claims court might then become less confidential and potentially accessed by others.
  4. Health Care Operations. Speare Psychological Services, P.A. may use and disclose personal health information about you to operate this practice. For example, Speare Psychological Services, P.A may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of my professional staff. Speare Psychological Services, P.A. may use and disclose this information to get your health plan to authorize services or referrals. Speare Psychological Services, P.A. may also use and disclose this information as necessary for medical reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. Speare Psychological Services, P.A. may also share your personal health information with our “business associates,” such as my billing software, that perform administrative services for my practice, my accountants that do my business accounting taxes and my computer repair/maintenance person. Speare Psychological Services, P.A. has a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information. Speare Psychological Services, P.A. may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts.
  5. Appointment Reminders. Speare Psychological Services, P.A. may use and disclose PHI to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.
  6. Notification and Communication With Family. Speare Psychological Services, P.A. may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. Speare Psychological Services, P.A. may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, Speare Psychological Services, P.A. will give you the opportunity to object prior to making these disclosures, although Jonathan Speare, Ph.D. Licensed Psychologist, may disclose this information in a disaster even over your objection if he believes it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
  7. Marketing. Speare Psychological Services, P.A. will not otherwise use or disclose your personal health information for marketing or accept any payment for other marketing communications without your prior written authorization. The authorization will disclose whether Speare Psychological Services, P.A. receives any compensation for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that authorization.
  8. Sale of Health Information. Speare Psychological Services, P.A. will not sell your personal health information without your prior written authorization. The authorization will disclose that Speare Psychological Services, P.A will receive compensation for your personal health information if you authorize us to sell it, and Speare Psychological Services, P.A. will stop any future sales of your information to the extent that you revoke that authorization.
  9. Required by Law. As required by law, Speare Psychological Services, P.A. will use and disclose your personal health information, but Jonathan Speare, Ph.D., Licensed Psychologist will limit his use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities. Speare Psychological Services, P.A. may disclose information when the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the Privacy Rule and state’s 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.
  10. Public Health. Speare Psychological Services, P.A. may, and are 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 Speare Psychological Services, P.A. reports suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.
  11. Health Oversight Activities. Speare Psychological Services, P.A. may, and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by law.
  12. Judicial and Administrative Proceedings. Speare Psychological Services, P.A. may, and will sometimes be required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. Speare Psychological Services, P.A. may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.
  13. Law Enforcement. Speare Psychological Services, P.A. may, and will sometimes be required by law, to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.
  14. Coroners. Speare Psychological Services, P.A. will be required by law, to disclose your health information to coroners in connection with their investigations of deaths.
  15. Public Safety. Speare Psychological Services, P.A. will be required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
  16. Specialized Government Functions. Speare Psychological Services, P.A. may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.
  17. Workers’ Compensation. Speare Psychological Services, P.A. may disclose your health information as necessary to comply with workers’ compensation laws. For example, to the extent your care is covered by workers’ compensation, Speare Psychological Services, P.A. will make periodic reports to your employer about your condition. Speare Psychological Services, P.A. will also be required by law to report cases of occupational injury or occupational illness to the employer or workers’ compensation insurer.
  18. Change of Ownership. In the event that this practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another health care provider.
  19. Breach Notification. In the case of a breach of unsecured protected health information, Speare Psychological Services, P.A. will notify you as required by law. In some circumstances our business associate(s) may provide the notification. Speare Psychological Services will provide notification by methods that are appropriate.
  20. Psychotherapy Notes. Speare Psychological Services, P.A. will not use or disclose your 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 my staff, and other trainees, 3) to defend ourselves if you sue Speare Psychological Services, P.A. and/or Jonathan Speare, Ph.D., Licensed Psychologist or bring some other legal proceeding, 4) if the law requires Speare Psychological Services, P.A. to disclose the information to you or the Secretary of HHS or for some other reason, 5) in response to health oversight activities concerning your psychotherapist, 6) to avert a serious and imminent threat to health or safety, or 7) to the coroner or medical examiner after you die. To the extent you revoke an authorization to use or disclose your psychotherapy notes, Speare Psychological Services, P.A. will stop using or disclosing these notes.

When This Practice May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, this practice will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. Speare Psychological Services, P.A. and/or Jonathan Speare, Ph.D., Licensed Psychologist will also obtain an authorization from you before using or disclosing Protected Health Information (PHI). If you do authorize this practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

B. Your Public Health Information Rights

  1. Right to Request Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, Speare Psychological Services, P.A. will abide by your request, unless we must disclose the information for treatment or legal reasons. Speare Psychological Services, P.A. and/or Jonathan Speare, Ph.D., Licensed Psychologist reserves the right to accept or reject any other request, and will notify you of our decision.
  2. Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. Speare Psychological Services, P.A. will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.
  3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access your personal health information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. Speare Psychological Services, P.A. will provide copies in your requested form and format if it is readily producible, or Speare Psychological Services, P.A. will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. Speare Psychological Services, P.A. will also send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary. Speare Psychological Services, P.A. may deny your request under limited circumstances. If we deny your request to access your child’s records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional.
  4. Right to Amend or Supplement. You have a right to request that Jonathan Speare, Ph.D., Licensed Psychologist amend your personal health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. Jonathan Speare, Ph.D., Licensed Psychologist is not required to change your health information, and will provide you with information about this practice’s denial and how you can disagree with the denial. Speare Psychological Services, P.A. and/or Jonathan Speare, Ph.D., Licensed Psychologist may deny your request if he does not have the information, if he did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. If, Jonathan Speare, Ph.D., Licensed Psychologist denies your request, you may submit a written statement of your disagreement with that decision, and he may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.
  5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your personal health information made by this practice, except that this practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with family) and 18 (specialized government functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.
  6. Right to a Paper or Electronic Copy of this Notice. You have a right to notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested.
  7. Right to Restrict Disclosures When You have Paid for Your Care Out-of-Pocket You have the right to restrict certain disclosures of protected health information to a health plan when you pay out-of-pocket in full for my services.
  8. Right to Be Notified if There is a Breach of Your Unsecured Protected Health Information (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. If you have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.

C. Changes to this Notice of Privacy Practices

Speare Psychological Services, P.A. reserves the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, Speare Psychological Services, P.A. is required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. Speare Psychological Services, P.A. will keep a copy of the current notice posted in our reception area, and a copy will be available at each appointment. We will also post the current notice on our website: www.JonathanSpeare.com

D. Complaints

Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: Mail: Civil Rights Coordinator, Minnesota Department of Human Services, Office for Equal Opportunity, PO Box 64997, St. Paul, MN 55164-0997, Phone: (651) 431-3040 (Voice), (866) 786-3945 (TTY/TDD), (800) 627-3529 (Minnesota Relay) (877) 627-3848 (Speech-to-Speech Relay) or OCRMail@hhs.gov

The complaint form may be found at www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf. You will not be penalized in any way for filing a complaint.

The effective date of this notice is September 23, 2013.