of Privacy Practices
This notice describes how medical and mental health information about you/your child may
be used and disclosed and how you can get access to this information. Please review this notice carefully.
child’s health record contains personal information about you/him/her and your/his/her health. Personal Health Information
(PHI) is information about you/your child that may identify you/him/her and that relates to your/his/her past, present or
future physical or mental health or condition and related health care services. This Notice of Privacy Practices describes
how I, Christine Becker, may use and disclose your/your child’s PHI in accordance with applicable law and the NASW Code
of Ethics. It also describes your/your child’s rights regarding how you may gain access to and control his/her PHI.
I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy
practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right
to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for
all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by posting
a copy on my website, www.ccbecker.com, and providing one to you upon request.
How I May Use and Disclose Health
Information About You/Your Child
• For Treatment. Your/your child’s PHI may be used and disclosed by
those who are involved in your/your child’s care for the purpose of providing, coordinating or managing your/your child’s
health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members.
I may disclose PHI to any other consultant only with your authorization.
• For Payment. I may use and disclose
PHI so that I can receive payment for the treatment services provided to you/your child. This will only be done with your
authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance
benefits, processing claims with your child’s insurance company, reviewing services provided to your child to determine
medical necessity or undertaking utilization review activities. If it becomes necessary to use collection processes due to
lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.
• For Health Care Operations. I may use or disclose, as needed, your/your child’s PHI in order to support my
business activities including, but not limited to, quality assessment activities, employee review activities, licensing and
conducting or arranging for other business activities. For example, I may share your/your child’s PHI with third parties
that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business
that requires it to safeguard the privacy of your/your child’s PHI. For training or teaching purposes PHI will be disclosed
only with your authorization.
• Judicial and Administrative Proceedings. In any judicial or administrative
proceeding, you have the right to refuse to authorize the disclosure of any communication between you, your child and me relating
to your/your child’s care and treatment. There are a few instances in which this privilege would not apply, and therefore,
in which I could testify in the judicial or administrative proceeding. Specifically, I may disclose such communications during
judicial or administrative proceedings, if:
(i) I determine that you/your child needs hospitalization or is a
threat to yourself or to others;
(ii) The communications were made in the course of a court-ordered psychiatric examination;
(iii) You/Your child is a party to a case and has introduced his/her mental or emotional state as an element of a claim
(iv) The testimony is given in connection with a care and protection proceeding, or a petition to dispense
with parental consent to adoption;
(v) It is in connection with any malpractice action brought by you against me, where
the disclosure is necessary for my defense;
(vi) The communications relate to your ability to provide care or custody
in a child custody or adoption case;
(vii) The communications were made in connection with and during an investigation
of allegations of child abuse, when I have made a report that I have reasonable cause to believe that child abuse is occurring;
(viii) I believe a child, a disabled person, or an elderly person in your care is suffering abuse or neglect.
• In an Emergency. I may disclose your/your child’s PHI to a physician who requests such records in the
treatment of a medical or psychiatric emergency. For example, if you/your child is unconscious and the doctor treating him/her
needs to know details regarding your/his/her medical history in order to decide on a course of treatment for you/your child,
I would disclose the PHI necessary for the doctor to treat you/your child during the emergency. If it is not possible to obtain
your consent to this disclosure, then notice of the disclosure will be provided to you as soon as possible.
Business Associates. Some services in my business I may obtain through contracts with business associates. For example, I
may contract with outside companies to provide legal services, accounting services, or billing services. When I contract with
a business associate, I may disclose health information to the business associate so it can do the job I’ve asked it
to do. To protect your/your child’s health information, I require the business associate to appropriately safeguard
your health information.
Required by Law
Under the law, I must make disclosures of your/your child’s
PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human
Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization:
Abuse and Neglect
• Judicial and Administrative Proceedings
• Deceased Persons
• Family Involvement in Care
• Health Oversight
• Law Enforcement
• National Security
• Public Health
• Public Safety (Duty to Warn)
Applicable law and ethical standards permit me to disclose information about you/your child without your authorization
only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization
are those that are:
• Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory
government agency audits or investigations (such as the social work licensing board or the health department)
Required by Court Order
• Necessary to prevent or lessen a serious and imminent threat to the health or safety
of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person
or persons reasonably able to prevent or lessen the threat, including the target of the threat.
I may use or disclose your/your child’s information to family members that are directly involved in your/your
child’s treatment with your verbal permission.
Uses and disclosures not specifically
permitted by applicable law will be made only with your written authorization, which may be revoked.
If you provide me with permission to use or disclose PHI about you/your child you may revoke that permission,
in writing, at any time. If you revoke your authorization, I will no longer use or disclose medical information about you/your
child for the purposes covered by the written authorization. However, I am unable to take back any disclosures that I have
already made with your authorization.
Your/Your Child’s Rights Regarding Your Child’s PHI
have the following rights regarding PHI I maintain about yourself/your child. To exercise any of these rights, please submit
your request in writing to me:
• Right of Access to Inspect and Copy. You have the right, which may be restricted
only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your/your child’s
care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that
access would be reasonably likely to endanger the life or physical safety of you, another person or your child. I may charge
a reasonable, cost-based fee for copies. I will act on your request within thirty days of receiving your request.
• Right to Amend. If you feel that the PHI I have about you/your child is incorrect or incomplete, you may ask me in
writing to amend the information although I am not required to agree to the amendment.
• Right to an Accounting
of Disclosures. You have the right to request an accounting of the disclosures that I make of your child’s PHI. This
is a list of certain disclosures I have made of your/your child’s PHI. To make this request, you should submit it in
writing to me. I may charge you a easonable fee if you request more than one accounting in any 12-month period.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information
I use or disclosure about you/your child for treatment, payment or health care operations. For example, you might request
that particularly sensitive information (such as the existence of drug
dependence) not be disclosed for any purpose.
I am not required to agree to your request. To request restrictions, you must submit your request in writing to me. In your
request, you must tell me (1) what information you want to limit, (2) whether you want to limit the use, disclosure, or both,
and (3) to whom you want the limits to apply (for example, disclosures to your insurance carrier.)
to Request Confidential Communication. You have the right to request that I communicate with you about medical matters in
a certain way or at a certain location. For example, you can ask that I only contact you at work or by mail.
Right to a Copy of this Notice. You have the right to a paper copy of this notice. You may ask me to give you a copy of this
notice at any time.
If you believe I have violated your or your child’s privacy rights,
you have the right to file a complaint in writing with me or with the Office for Civil Rights, U.S. Department of Health and
Human Services, Government Center, J.F. Kennedy Federal Building--Room 1875, Boston, Massachusetts 02203.
not retaliate against you for filing a complaint.
The effective date of this Notice is January 14, 2014.