Attune & Bloom Psychology PLLC 

Dr. Lisa Nail, Psy.D., MSCP 

Pennsylvania Notice Form 
 

Notice of Psychologists’ 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 
I may use or disclose your protected health information (PHI) for treatment, payment, and health care operations 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 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 psychologist. 
- 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 healthcare or to determine eligibility or coverage. 
- 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 coordination. 
- “Use” applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. 
- “Disclosure” applies to activities outside of my office such as releasing, transferring, or providing access to information about you to other parties. 
 

II. Uses and Disclosures Requiring Authorization 
I 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 when I am asked for information for purposes outside of treatment, payment, and 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 medical record. These notes are given a greater degree of protection than PHI. I do not necessarily keep psychotherapy notes on all patients or for all sessions. 
 

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, and the law provides the insurer the right to contest the claim under the policy. 

 
III. Uses and Disclosures with Neither Consent nor Authorization 
I may use or disclose PHI without your consent or authorization in the following circumstances. 
- Child Abuse: If I have reasonable cause, on the basis of my professional 
judgment, to suspect abuse of children with whom I come into contact in my professional capacity, I am required by law to report this to the Pennsylvania Department of Public Welfare. 
- Adult and Domestic Abuse: If I have reasonable cause to believe that an older adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), I may report such to the local agency which provides protective services. 
-  Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services, I provided you or the records thereof, such information is privileged under state law, and I will not release the information without your written consent, 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 will be informed in advance if this is the case. 
- Serious Threat to Health or Safety: If you express a serious threat, or intent to kill or seriously injure an identified or readily identifiable person or group of people, and I determine that you are likely to carry out the threat, I must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of the threat or intent. 
- Worker’s Compensation: If you file a worker’s compensation claim, I will be required to file periodic reports with your employer, which shall include, where pertinent, history, diagnosis, treatment, and prognosis. 
- Impaired Driving: If it appears that you are unable to safely operate a vehicle at the time of your departure from the office, your psychologist is obligated to inform the police in order to protect the safety of the general public. Likewise, if it is apparent that you are unable to safely operate a vehicle for medical or other reasons and disclose that you continue to drive, your psychologist may be required to notify authorities to ensure public safety. 

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 about you. 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. Upon 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. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, I 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. 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 for which you have neither provided consent nor authorization (as described in Section III of this Notice). 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 Notification of any Breach: If there is a breach of your confidentiality, then I must inform you as well as Health and Human Services. A breach means that information has been released without authorization or without legal authority unless I (the covered entity) can show that there was a low risk that the PHI has been compromised because the unauthorized person did not view the PHI or it was de-identified. 
- Self-Pay Right to Restriction: If you are self-pay, then you may restrict the information sent to insurance companies. 
- Most uses and disclosures of psychotherapy notes and of protected health information for marketing purposes and the sale of protected health information require an authorization. Other uses and disclosures not described in the notice will be made only with your written authorization. You must sign an authorization (release of information form) for releases unless it is for purposes already mentioned in this Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired drivers, etc.). 

- Right of Electronic Record: You have a right to receive a copy of your Protected Health Information in an electronic format or (through a written authorization) designate a third party who may receive such information. 

Psychologist’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 I notify you of such changes, however, I am able to abide by the terms currently in effect. 
 

V. Questions and Complaints 
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me. 
 

If you believe that your privacy rights have been violated and wish to file a complaint, 
you may send your written complaint to me. 
 

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

You have specific rights under the Privacy Rule. I will not retaliate against you for 
exercising your right to file a complaint.