Dietchman Leavell and Associates, LLC

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:

“PHI” refers to information in your health record that could identify you.
“Treatment, Payment, and Health Care Operations”

– Treatment is when Dietchman, Leavell and Associates provides, coordinates or manages
your health care and other services 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.

Two Kansas City area
locations to serve you.

Dietchman, Leavell and Associates, LLC
Psychological and Counseling Services