Dr. Melis Alkin, Clinical Psychologist Inc.
Providing individual and couples therapy. Redondo Beach, California, in person, telehealth in CA and NY. EMDR, Relational Life Therapy
Dr. Melis Alkin, Clinical Psychologist Inc.
Providing individual and couples therapy. Redondo Beach, California, in person, telehealth in CA and NY. EMDR, Relational Life Therapy
Introduction
The Federal Health Insurance Portability and Accountability Act (HIPAA) requires mental health professionals to issue this official Notice of Privacy Practices. This notice describes how information about you is protected, the circumstances under which it may be used or disclosed and how you may gain access to this information. Please review it carefully.
For psychotherapy to be beneficial, it is important that you feel free to speak about personal
matters, secure in the knowledge that the information you share will remain confidential. You have the right to the confidentiality of your medical and psychological information, and this practice is required by law to maintain the privacy of that information.
This practice is required to abide by the terms of the Notice of Privacy Practices currently in effect, and to provide notice of its legal duties and privacy practices with respect to protected health and psychological information. If you have any questions about this Notice, please contact the Privacy Officer at this practice.
Who Will Follow This Notice
Any health care professional authorized to enter information into your medical record, all employees, staff, and other personnel at this practice who may need access to your information must abide by this Notice. All subsidiaries, business associates (e.g., a billing service), sites and locations of this practice may share medical information with each other for treatment, payment purposes or health care operations described in this Notice. Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be shared.
Uses and Disclosures 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. The following should help clarify these terms:
• PHI refers to information in your health record that could identify you. For example, it may include your name, the fact you are receiving treatment here, and other basic information pertaining to your treatment.
• Use applies only to activities within my office and practice group, such as sharing, employing, applying, utilizing, and analyzing information that identifies you.
• Disclosure applies to activities outside of my office or practice group, such as releasing, transferring, or providing access to information about you to other parties.
• Authorization is your written permission to disclose confidential health information. All authorizations to disclose must be made on a specific and required form.
• Treatment is when we provide, coordinate, or manage your health care and other services related to your health care. For example, with your written authorization we may provide your information to your physician to ensure the physician has the necessary information to diagnose or treat you.
• Payment Your PHI may be used, as needed, in activities related to obtaining payment for your health care services. This may include the use of a billing service or providing you documentation of your care so that you may obtain reimbursement from your insurer.
• Health Care Operations are activities that relate to the performance and operation of my practice. We may use or disclose, as needed, your protected health information in support of business activities. For example, when we review an administrative assistant’s performance, we may need to review what that employee has documented in your record.
Written Authorizations to Release PHI
Any other uses and disclosures of your PHI beyond those listed above will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke your authorization at any time, in writing.
Uses and Disclosures without Authorization
The ethics code of the American Psychological Association, California State law, and the federal HIPAA regulations all protect the privacy of all communications between a client and a mental health professional. In most situations, we can only release information about your treatment to others if you sign a written authorization. This Authorization will remain in effect for a length of time you and we determine. You may revoke the authorization at any time, unless we have taken action in reliance on it. However, there are some disclosures that do not require your Authorization. We may use or disclose PHI without your consent in the following circumstances:
• Child Abuse – If we have reasonable cause to believe a child may be abused or neglected, we must report this belief to the appropriate authorities.
• Adult and Domestic Abuse – If we have reason to believe that an individual such as an elderly or disabled person protected by state law has been abused, neglected, or financially exploited, we must report this to the appropriate authorities.
• Health Oversight Activities – we may disclose your PHI to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions. If a client files a complaint or lawsuit against me, we may disclose relevant information regarding that patient in order to defend myself.
• Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information by any party about your treatment and the records thereof, such information is privileged under state law, and is not to be released without a court order. Information about all other psychological services (e.g., psychological evaluation) is also privileged and cannot be released without your authorization 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 must be informed in advance if this is the case.
• Serious Threat to Health or Safety – If you communicate to me a specific threat of imminent harm against another individual or if we believe that there is clear, imminent risk of injury being inflicted against another individual, we may make disclosures that we believe are necessary to protect that individual from harm. If we believe that you present an imminent, serious risk of injury or death to yourself, we may make disclosures we consider necessary to protect you from harm.
• Worker's Compensation – we may disclose PHI 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.
Special Authorizations
Certain categories of information have extra protections by law, and thus require special written authorizations for disclosures.
• Psychotherapy Notes – we will obtain a special authorization before releasing your Psychotherapy Notes. "Psychotherapy Notes" are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your record. These notes are given a greater degree of protection than PHI.
• HIV Information – Special legal protections apply to HIV/AIDS related information. We will obtain a special written authorization from you before releasing information related to HIV/AIDS.
• Alcohol and Drug Use Information – Special legal protections apply to information related to alcohol and drug use and treatment. We will obtain a special written authorization from you before releasing information related to alcohol and/or drug use/treatment. You may revoke all such authorizations (of PHI, Psychotherapy Notes, HIV information, and/or Alcohol and Drug Use Information) at any time, provided each revocation is in writing, signed by you, and signed by a witness. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
Patient's Rights and Psychologist's/Psychotherapist’s Duties
Patient's Rights:
• Right to Request Restrictions – You have the right to request restrictions on certain uses/disclosures of PHI. However, we are not required to agree to the request.
• Right to Receive Confidential Communications by Alternative Means – You have the right to request and receive confidential communications by alternative means and locations. (For example, you may not want a family member to know that you are seeing me. On your request, we will send your bills to another address.)
• Right to Inspect and Copy – You have the right to inspect or obtain a copy of PHI in my records as these records are maintained. In such cases we will discuss with you the process involved.
• Right to Amend – You have the right to request an amendment of PHI for as long as it is maintained in the record. We may deny your request. If so, we will discuss with you the details of the amendment process.
• Right to an Accounting – You generally have the right to receive an accounting of all disclosures of PHI. We can discuss with you the details of the accounting process.
• Right to a Paper Copy – You have the right to obtain a paper copy of the Notice of Privacy Practices from me upon request.
Psychologist's/Psychotherapist’s Duties:
• 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.
• I reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, I am required to abide by the terms currently in effect.
• If I revise my policies and procedures, I will notify you at our next session, or by mail at the address you provided me.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at this practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or discriminated against for filing a complaint.
If you have any questions about this Notice, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me:
Melis Alkin, Psy.D. 1200 Aviation Blvd #102 Redondo Beach, CA 90278
(424) 254 8292
Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on May 21, 2003 and remain so unless new notice provisions effective for all protected health information are enacted accordingly.
YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE
(OMB Control Number: 0938-1401)
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgicalcenter, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivistservices. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you unless you givewritten consent and give up your protections.
You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
· You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
· Your health plan generally must:
o Cover emergency services without requiring you to get approval for services in advance (priorauthorization).
o Cover emergency services by out-of-network providers.
o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
o Count any amount you pay for emergency services or out-of-network services toward your deductibleand out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact: California Secretary of the State, 1500 11th Street, Sacramento, CA, 95814, (916) 653-6814
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.