Notice of Dietchman, Leavell and Associates’ Policies and Practices to
Protect the Privacy of Your Health Information
Effective Date 4/14/03
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND THERAPEUTIC 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
Dietchman, Leavell and Associates 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:
related to your health care. An example of treatment would be when Dietchman, Leavell and Associates consults with another
health care provider, such as your family physician or another therapist.
- Payment is when Dietchman, Leavell and Associates obtains reimbursement for your healthcare. Examples of payment are
when Dietchman, Leavell and Associates 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 our 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 coordination.
II. Uses and Disclosures Requiring Authorization
Dietchman, Leavell and Associates may use or disclose PHI for purposes outside of treatment, payment, or 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 when Dietchman, Leavell and Associates is asked for
information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you
before releasing this information. We will also need to obtain an 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 clinical 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) Dietchman, Leavell and Associates has 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.
III. Uses and Disclosures with Neither Consent nor Authorization
Dietchman, Leavell and Associates may use or disclose PHI without your consent or authorization in the following
circumstances:
“Eligible adult” means any person 60 years of age or older, or an adult with a handicap (substantially limiting mental or physical
impairment) between the ages of 18 and 59 who is unable to protect his or her own interests or adequately perform or obtain
services which are necessary to meet his or her essential human needs.
Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about
your diagnosis or treatment and the records thereof, such information is privileged under state law, and we will not release
information without written authorization from you or your personal or legally-appointed representative, 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. We will inform
you in advance if this is the case. If you have been referred through the Division of Family Services, please be advised that by
contract we are mandated reporters and therefor required to submit periodic progress reports to your caseworker. We will also
share information with the court’s and with officers of the court as needed.
IV. Patient's Rights and Psychologist's Duties
Patient's Rights:
Dietchman, Leavell and Associates Duties:
V. Complaints
If you are concerned that anyone at Dietchman, Leavell and Associates has violated your privacy rights, or you disagree with a
decision we made about access to your records, you may contact Renee L. Dietchman at (816) 531-7737 to file a complaint.
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.
Protect the Privacy of Your Health Information
Effective Date 4/14/03
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND THERAPEUTIC 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
Dietchman, Leavell and Associates 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”
related to your health care. An example of treatment would be when Dietchman, Leavell and Associates consults with another
health care provider, such as your family physician or another therapist.
- Payment is when Dietchman, Leavell and Associates obtains reimbursement for your healthcare. Examples of payment are
when Dietchman, Leavell and Associates 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 our 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 coordination.
- “Use” applies only to activities within our practice group, such as sharing, employing, applying, utilizing, examining, and
analyzing information that identifies you. - “Disclosure” applies to activities outside of our practice group, such as releasing, transferring, or providing access to
information about you to other parties.
II. Uses and Disclosures Requiring Authorization
Dietchman, Leavell and Associates may use or disclose PHI for purposes outside of treatment, payment, or 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 when Dietchman, Leavell and Associates is asked for
information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you
before releasing this information. We will also need to obtain an 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 clinical 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) Dietchman, Leavell and Associates has 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.
III. Uses and Disclosures with Neither Consent nor Authorization
Dietchman, Leavell and Associates may use or disclose PHI without your consent or authorization in the following
circumstances:
- Child Abuse – If we have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect, or if
we observe a child being subjected to conditions which would reasonably result in abuse or neglect, we must
immediately report such information to the Missouri Division of Family Services. We must also report sexual abuse or
molestation of a child under 18 years of age to Family Services. We may also report child abuse or neglect to a law
enforcement agency or juvenile office.
- Adult and Domestic Abuse – If we have reasonable cause to suspect that an eligible adult (defined below) presents a
likelihood of suffering physical harm or is in need of protective services, we must report such information to the
Missouri Department of Social Services.
“Eligible adult” means any person 60 years of age or older, or an adult with a handicap (substantially limiting mental or physical
impairment) between the ages of 18 and 59 who is unable to protect his or her own interests or adequately perform or obtain
services which are necessary to meet his or her essential human needs.
- Health Oversight Activities – The Missouri Attorney General’s Office may subpoena records from Dietchman, Leavell
and Associates relevant to disciplinary proceedings and investigations conducted by the Missouri State Committee of
Psychologists or other professional licensing board.
Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about
your diagnosis or treatment and the records thereof, such information is privileged under state law, and we will not release
information without written authorization from you or your personal or legally-appointed representative, 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. We will inform
you in advance if this is the case. If you have been referred through the Division of Family Services, please be advised that by
contract we are mandated reporters and therefor required to submit periodic progress reports to your caseworker. We will also
share information with the court’s and with officers of the court as needed.
- Serious Threat to Health or Safety – When we judge that disclosure is necessary to protect against a clear and substantial
risk of imminent serious harm being inflicted by you on yourself or another person, we must disclose your relevant
confidential information to the appropriate professional workers, public authorities, the potential victim, his or her family,
or your family.
- Workers' Compensation – If you file a worker’s compensation claim, we must permit your record to be copied by the
Missouri Labor and Industrial Commission or the Division of Worker’s Compensation of the Missouri Department of
Labor and Industrial Relations, your employer, you and any other party to the proceedings.
IV. 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, Dietchman, Leavell and Associates 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 being seen through Dietchman, Leavell and Associates. 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 (or both) of PHI in our mental health and
billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your
access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request,
we will discuss with you 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.
Dietchman, Leavell and Associates may deny your request. On your request, 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 disclosures of PHI. On your request,
Dietchman, Leavell and Associates 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 Dietchman, Leavell and Associates
upon request, even if you have agreed to receive the notice electronically.
Dietchman, Leavell and Associates Duties:
- We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy
practices with respect to PHI.
- We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such
changes, however, we are required to abide by the terms currently in effect. With notification we reserve the right to
make the revised or changed privacy practices applicable to protected health information we already have about you as
well as any information we receive in the future.
- A copy of our current notice will be posted in our office. Prior to a material change to the uses or disclosures, your
rights, our legal duties, or other privacy practices stated in this notice, we will revise this notice and make the revised
version of the notice available upon request. We will also post the notice, as revised, in our offices. The notice will
contain an effective date on the first page.
V. Complaints
If you are concerned that anyone at Dietchman, Leavell and Associates has violated your privacy rights, or you disagree with a
decision we made about access to your records, you may contact Renee L. Dietchman at (816) 531-7737 to file a complaint.
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.
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Dietchman, Leavell and Associates, LLC
Psychological and Counseling Services
3210 Gillham Road Kansas City, Missouri 64109 Telephone: (816) 531-7737 Facsimile (816) 531-7738