Illinois Notice Form

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


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 with your written authorization. I may also disclose PHI for payment purposes with your general consent. To help clarify these terms, here are some definitions:

  • PHI” refers to information in your health record that could identify
  • Treatment, Payment, and Health Care Operations
    • Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another
    • Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or
    • Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care
  • Use” applies only to activities within my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies
  • Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other
  • Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required

Other Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. In those instances when I am asked for information for purposes outside of treatment, payment, or health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your record.  These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I 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.

Uses and Disclosures without Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

  • Child Abuse – If I have reasonable cause to believe a child known to me in my professional capacity may be an abused child or a neglected child, I must report this belief to the appropriate authorities.
  • Adult and Domestic Abuse – If I have reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, I must report this belief to the appropriate authorities.
  • Health Oversight Activities – I may disclose protected health information regarding you to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions.
  • Judicial and Administrative Proceedings If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law, and I must not release such information without a court order. I can release the information directly to you on your request. Information about all other psychological services 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 I believe that there is clear, imminent risk of physical or mental injury being inflicted against another individual, I may make disclosures that I believe are necessary to protect that individual from harm. If I believe that you present an imminent, serious risk of physical or mental injury or death to yourself, I may make disclosures I consider necessary to protect you from harm.
  • Worker’s Compensation – I may disclose protected health information 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.

There may be additional disclosures of PHI that I am required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common.

Patient’s Rights and Psychologist’s Duties

 Patient’s Rights:

  • Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am 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 seeing me. On your request, I 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 in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record and Psychotherapy Notes. On your request, I will discuss with you the details of the request for access 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. I may deny your request. On your request, I will discuss with you the details of the amendment process.
  • Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, I will 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 from me upon request, even if you have agreed to receive the notice electronically.
  • Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket. You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.

Psychologist’s Duties:

  • I am required by law to maintain 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 I 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 by mail.

Breach Notification Addendum to Policies & Procedures

  1. When the Practice becomes aware of or suspects a breach, as defined in Section 1 of the breach notification Overview, the Practice will conduct a Risk Assessment, as outlined in Section 2.A of the Overview. The Practice will keep a written record of that Risk Assessment.
  2. Unless the Practice determines that there is a low probability that PHI has been compromised, the Practice will give notice of the breach as described in Sections 2.B and 2.C of the breach notification Overview.
  3. The risk assessment can be done by a business associate if it was involved in the breach. While the business associate will conduct a risk assessment of a breach of PHI in its control, the Practice will provide any required notice to patients and HHS.
  4. After any breach, particularly one that requires notice, the Practice will re-assess its privacy and security practices to determine what changes should be made to prevent the re-occurrence of such breaches. [Attach a copy of the breach notification section (Section B) of Update]
  1. Right to Be Notified if There is a Breach of Your Unsecured 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.


If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact [add name, or title, and telephone number of a person or office to contact for further information.]                                                           

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on                               [add date, which may not be earlier than the date on which the notice is printed or otherwise published.]

[If you (the psychologist) elect to limit the uses or disclosures that you are permitted to make under this subpart, add the following:]

I will limit the uses or disclosures that I will make as follows:                      

[If you (the psychologist) want to apply a change in your more limited uses and disclosures to PHI created or received prior to issuing a revised notice, the revised notice must include a statement that new reserve the right to change the terms of the notice and to make the new notice provisions effective for all protected health information that you maintain. The statement must also describe how you will provide individuals with a revised notice.    (See example below.)]

I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by                     [Describe how you will provide individuals with a revised notice.]

HIPAA – Health Insurance Portability and Accountability Act

A new federal law provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have  taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under  your policy; or if you have not satisfied any financial obligations you have incurred.

You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you professional records. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set  for treatment, your progress towards those goals, your medical

and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier, and treatment notes. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive your records, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. [I am sometimes willing to conduct this review  meeting without charge.] In most circumstances, I am allowed to charge a copying fee of $.50 cents per page (and copying expense for the file of $35 for clients, and $75.00 for outside professionals and insurance companies due to the added responsibility that I assume by releasing records to these entities.

I the client (or his or her parent or guardian) have read the above information on all four pages of this treatment contract and I understand and agree to its contents. I have gone over this contract with Dr. Allen, and I understand these policies, rules, questions, issues of confidentiality, payment issues, and my rights in therapy. I have had all of my initial questions answered fully, and I understand that I may ask questions at any time concerning all aspects of my therapy. I do hereby seek and consent to take part in the treatment by Dr. Ben Allen. I understand that developing a treatment plan with this therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist. I am aware that I may stop my treatment with this therapist at any time. The only thing I will still be responsible for is paying for the services I have already received, and providing a final phone conversation for closure. My signature below also indicates that I have acknowledged my rights in the HIPAA notice Form.

Signature of Client (or parent/guardian)                                                         Date

Minor’s Signature (if client is over 12 years old)                                            Date

Printed Name

I, Dr. Ben Allen, have discussed these issues with the client (and/or his or her parent or guardian). I believe this person fully understands the issues, and I find no reason to believe that this person is not fully competent to give informed consent to treatment.

Signature of Therapist                                                                                        Date


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