Notice of Privacy Practices

Protected Health Information

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Effective April 14, 2003

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.​

 

This Notice has been prepared by Child and Family Psychological Associates (CFPA LLC). It tells you how Protected Health Information about you can be created, shared, protected and maintained.

 

What is my Protected Health Information?
·Anything from the past, present or future;
·About your mental or physical health or condition; 
·That is spoken, written, or electronically recorded, and is;
·Created by or given to anyone providing care to you; a health plan; a public health authority; your employer; your insurance company; your school or university; or anyone who processes health information about you.

 

What Rights Do I Have About My Protected Health Information?
·You have the right to consent to the use and disclosure of your Protected Health Information for the limited purpose of diagnosing you and administering and paying for your treatment.[1]
·You have the right to authorize the sharing of your Protected Health Information for other purposes.
·You have the right to see and copy your Protected Health Information. Exceptions to this information are psychotherapy notes; information prepared for certain legal proceedings; and information maintained by clinical laboratories.
·You have the right to request that we amend your Protected Health Information.
·You have the right to be informed about and to share your Protected Health Information in a confidential manner chosen by you. The manner you choose must be possible for us to do.
·You have the right to restrict how we use and disclose your Protected Health Information. We do not have to agree to your restrictions. If we do agree, we must follow your restrictions.
·You have the right to obtain a copy of a record of certain disclosures of your Protected Health Information that we make. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request.
·You have the right to have a copy of this Privacy Notice. We may change the terms of this Privacy notice from time to time. You can always get a copy of the current Privacy Notice by requesting it from Drs. Brewster, Coleman, Matzke, Putt or Rafter.

 

Consent
What can be done with my information if I consent to disclose it for my diagnosis or to administer and pay for my treatment?

With your consent, we can share information about your health with other specialists so that you can receive the most appropriate treatment. For example, your counselor could share with your treating physician that you are depressed. The doctor could then prescribe medication to help you feel better.

With your consent, we can share information about when and for what purpose you were seen, so that we can be paid for treating you. For example, we could send a form to your insurance company stating when and for what condition you were at the office. They can then send us money to help cover your costs of being seen.

With your consent, we can share information with other healthcare entities to ensure that you obtain the correct diagnosis. For example, if you were complaining about being tired all the time, we could obtain a sample of your blood and sent it to a blood laboratory. The blood laboratory could send us back information that your blood sample contained high sugar levels. This could help us determine whether you have diabetes.

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Can I revoke my consent?
Yes. You can revoke your consent. You must do this in writing and bring it to us so that we can stop using and disclosing your Protected Health Information. We are permitted to use and disclose your Protected Health Information based on your consent until we receive your revocation in writing. However, if you revoke your consent, we reserve the right to refuse to provide further treatment to you, on the basis of your refusal to allow us to share your information for purposes of treatment, payment, and healthcare operations.

 

Authorization

What can be done with my information if I authorize its disclosure for other purposes?
With your permission, we can share your Protected Health Information for reasons other than to diagnose you and to administer and pay for your treatment. For example, you might agree to allow us to share your Protected Health Information with a drug company so that it can send you information about new medications to treat your condition.

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Can I revoke my authorization?
Yes. You can revoke your authorization. You must do this in writing and bring it to us so that we can stop sharing your Protected Health Information. We are permitted to share your Protected Health Information based on your authorization until we receive your revocation in writing.

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Are there any circumstances when my information can be shared without my consent or authorization?
Yes. Your Protected Health Information can be shared without your prior consent or authorization:
·In an emergency so long as consent is obtained as soon as possible;
·When required by law:
·For public health activities according to specific requirements
·To protect victims of abuse, neglect or domestic violence according to specific requirements
·For health oversight activities according to specific requirements
·For judicial and administrative proceedings according to specific requirements
·For law enforcement purposes according to specific requirements
·To a coroner/medical examiner according to specific requirements
·To a funeral director according to specific requirements
·For organ/eye/tissue donation according to specific requirements
·For research purposes according to specific requirements
·To avert serious threats to health or safety according to specific requirements
·To facilitate specialized government functions according to specific requirements
·To correctional institutions for specific reasons according to specific requirements
·To facilitate eligibility determinations or enrollment into public benefit programs according to specific requirements
·For Workers Compensation according to specific requirements
When there are substantial communication barriers and it is reasonable to believe that
you are giving your consent or authorization.

 

What about any other uses of my medical information?
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

 

What will you do to protect my health information?
We will maintain the privacy of your Protected Health Information as required by law. At your request, we will provide you with a Privacy Notice containing our legal responsibilities and privacy practices regarding Protected Health Information.
We will follow the terms of the Privacy Notice currently in effect.

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Use of Email

E-mail can be used to contact staff for routine questions/scheduling, but is not to be used for emergencies as there may be a delay in reading your message.Please be aware that confidentiality of e-mail cannot be guaranteed.

 

We reserve the right to change the terms contained in this Privacy Notice. If we do this, it will affect all Protected Health Information maintained by us. We will notify you that we have changed the Privacy Notice by posting it at our offices, and by mailing it to you at the address you provide.

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What can I do if I have questions or want to complain about the use and disclosure of my Protected Health Information?
All questions and complaints about the use and disclosure of your Protected Health Information may be sent to the provider(s) listed below:

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Robert M. Brewster, Ph.D., Psychologist

David J. Coleman, Ph.D., Psychologist

Abigail L. Leslie, Psychologist

Geoffrey E. Putt, Psy.D., Psychologist

Erin M. Rafter, Ph.D., Psychologist

Sarah A. Tirpak, MA, Therapist

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330 923-9344
822 Portage Trail, Cuyahoga Falls, OH 44221

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We may not retaliate against you for complaining about the use and disclosure of your Protected Health Information.​

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