GOOD LIFE 

POSITIVE PSYCHOLOGY  

HIPAA Privacy Notice

 NOTICE FORM

Notice of Policies and Practices to Protect the Privacy of Your Health Information

THIS 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. Uses and Disclosures for Treatment, Payment, and Health Care Operations

GOOD LIFE POSITIVE PSYCHOLOGY 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 refers to the direct provision of services, coordination of care, and

consultation related to your health care. An example of treatment would be when your provider consults with another health care provider, such as your family physician, a psychiatrist or another licensed mental health professional. - Payment is when your provider obtains reimbursement for your

healthcare. Examples of payment are when your provider discloses your

PHI to your health insurer to obtain reimbursement for your health care or

to determine eligibility or coverage

- Health Care Operations are activities that relate to the performance and operation of GOOD LIFE POSITIVE PSYCHOLOGY. Examples of healthcare 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 GOOD LIFE POSITIVE PSYCHOLOGY such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of GOOD LIFE POSITIVE PSYCHOLOGY, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

GOOD LIFE POSITIVE PSYCHOLOGY 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, Good Life Center for Mental Health, LLC will obtain an authorization from you before

releasing this information.

You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization (1) retroactively, as Good Life Center for Mental Health, LLC relied 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. Please note that your therapist may elect to keep a second set of records referred to as “Psychotherapy Notes”. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of your conversations with your provider, your providers’ analysis of those conversations, and how they impact on your treatment. They also contain particularly sensitive information that you may reveal to us that is not required to be included in your PHI. HIPAA provides additional protection for psychotherapy notes, and most uses or disclosures of psychotherapy notes require your written permission. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it.

III. Uses and Disclosures with Neither Consent nor Authorization

GOOD LIFE POSITIVE PSYCHOLOGY may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If there is reasonable cause to believe that a child has been subject to abuse, your provider is mandated by law to report this immediately to the 

Division of Child Protection and Permanency or other emergency agencies.

• Adult and Domestic Abuse: If there is reasonable cause to believe that a vulnerable adult is the subject of abuse, neglect, or exploitation, your provider is mandated by law to report the information to the county adult protective services provider.

• Health Oversight: If state regulatory bodies Board of Psychological Examiners or Board of Social Work Examiners issue a subpoena, your provider may be compelled to testify before the Board and produce your relevant records and papers.

• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that you have received at GOOD LIFE POSITIVE PSYCHOLOGY and/or the records thereof, such information is privileged under state law, and GOOD LIFE POSITIVE PSYCHOLOGY must not release this information without written authorization from you or your legally appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or when the evaluation is court ordered. GOOD LIFE POSITIVE PSYCHOLOGY must inform you in advance if this is the case.

• Serious Threat to Health or Safety: If you communicate to your provider a threat of

imminent serious physical violence against a readily identifiable victim or yourself or the public and he or she believes you intend to carry out that threat, your provider must take steps to warn and protect you and others. Your provider also must take such steps, even if you have not made a specific verbal threat but there is reasonable concern about you being a danger to yourself or others. The steps your provider takes to warn and protect may include: arranging for you to be admitted to a psychiatric unit of a hospital or other health care facility, advising the police of your threat and the identity of the intended victim, warning the intended victim or his or her parents if the intended victim is under 18, and warning your parents if you are under 18. To reduce the risk of harm from firearms, your provider is required by law to call the police and provide information about where you live, if he or she believes there is an imminent risk of harm to you or others.

• Worker’s Compensation: If you file a worker's compensation claim, your therapist may be required to release relevant information from your mental health records to a participant in the worker’s compensation case, a reinsurer, the health care provider, medical and non- medical experts in connection with the case, the Division of Worker’s Compensation, or the Compensation Rating and Inspection Bureau.

IV. Patient's Rights and Mental Health Provider 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, GOOD LIFE POSITIVE PSYCHOLOGY 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. (For example, you may not want a family member to know that you are receiving services. Upon your request, GOOD LIFE POSITIVE PSYCHOLOGY will send your bills to another address.)

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and billing records used to make decisions about you for as long as the PHI is maintained in the record. GOOD LIFE POSITIVE PSYCHOLOGY may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, your provider will discuss 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. Your request may be denied. On your request, your provider will explain 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, your provider will explain the details of the accounting process.

• Right to a Paper Copy – You have the right to obtain a paper copy of the notice upon request, even if you have agreed to receive the notice electronically.

Mental Health Provider Duties:

• The law requires service providers to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.

• GOOD LIFE POSITIVE PSYCHOLOGY reserves the right to change the privacy policies and practices described in this notice. Unless we inform you of such changes, our practice is required to abide by the terms currently in effect.

• If we revise the policies and procedures, and you are an active patient, we will inform you of the changes in policy in person. If you have discontinued services, we will provide you with a revised notice, upon request.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision about access to your records or have other concerns about your privacy rights, you may discuss this with your provider.

If you believe that your privacy rights have been violated and wish to file a complaint, you may send your written complaint to Chris Mace, PhD, Privacy Officer

at GOOD LIFE POSITIVE PSYCHOLOGY , Address

You may send a written complaint to the Secretary of the U.S. Department of Health and Human Services. GOOD LIFE POSITIVE PSYCHOLOGY, will provide you with the appropriate address, upon request.

You have specific rights under the Privacy Rule. GOOD LIFE POSITIVE PSYCHOLOGY and its employees will not retaliate against you for exercising your right to file a complaint.