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Notice of Privacy Practices & Client Bill of Rights

PREMIER SPORT PSYCHOLOGY, PLLC

7401 Metro Blvd, Suite 510 Edina, MN 55439

OFFICE: 952.835.8513 FAX: 952.835.6313

www.PremierSportPsychology.com

As a consumer of psychological services offered by psychologists licensed by the state of Minnesota, you have the right to:

  • Expect that the psychologist has met the minimal qualifications of training and experience required by state law;
  • Examine public records maintained by the Board of Psychology, which contain the credentials of the psychologist;
  • Obtain a copy of the rules of conduct from the State Register and Public Documents Division, Department of Administration: 117 University Avenue, Saint Paul, MN 55155;
  • Report complaints to the Board of Psychology: Minnesota Board of Psychology 335 Randolph Avenue, Suite 270 St. Paul, MN 55102 Phone:  612-617-2230 Fax:  651-797-1372 Email:  psychology.board@state.mn.us
  • Be informed of the psychologist’s areas of clinical competence as submitted to the Board of Psychology.  Premier Sport Psychology’s sport psychologists’ competencies include:

Providing individual, group/team therapy and mental skills training to children, adolescents and adults, and consultation to support staff, medical team members or other organizational client stakeholders.

Providing sport psychology services to athletes, coaches, & sport personnel from all competitive levels

Administration and interpretation of standardized measures of personality, cognitive functioning, aptitudes, and interests to adolescents and adults

Designing and implementing psycho-educational workshops for, providing training to, and teaching adolescents and adults

Conducting psychological research

Providing clinical supervision and training to psychology graduate students

Teaching educational courses in psychology

Providing organizational consulting services to family-owned and privately held organizations

  • Be provided with a non-technical explanation about the nature and purpose of the psychological procedures to be used in your treatment, upon request;
  • Be free from being the object of discrimination on the basis of race, religion, gender, or other unlawful categories while receiving psychological services;
  • Be informed of the cost of professional services before receiving the services;
  • Be free from exploitation for the benefit or advantage of the psychologist;
  • Privacy as defined by rule and law;
  • Have access to your records as provided in subpart 1a and Minnesota Statutes section 144.335 subdivision 2:

Upon request, the psychologist will supply complete and current information in non-technical language about your diagnosis, treatment, and prognosis if you meet criteria for a mental health diagnosis.

Upon written request, the psychologist will promptly furnish copies of your records or, with your consent, a summary of the record.

If the psychologist reasonably determines that the information you have requested would be detrimental to your physical and mental health, the psychologist may withhold that information from you and supply it instead to an appropriate third party or other treatment provider.  That third party or treatment provider may release the information to you.

The psychologist may also withhold information that you have requested if, prior to your request, that psychologist has defined and described a specific basis for withholding that information.

  • Be informed about disclosures of your private records that may be made without your written consent.  Your information shared with the psychologist will be kept confidential unless you are in imminent risk of hurting yourself, you are in imminent risk of hurting another person, you know of minors or vulnerable adults who are being hurt or neglected, or if you are a woman who is pregnant and using certain classes of illicit drugs.  In those situations, appropriate emergency or health care personnel will be contacted in order to address those safety issues.  If you have been exploited or abused by a previous psychological treatment provider, that provider’s licensing board will be contacted.  Additionally, if a subpoena is issued and requires that a copy of your counseling records be turned over, the psychologist will be required to provide a copy of your records to comply with the court order. If you have concerns about the services you have been provided, you may also choose to file a complaint to your psychologist’s supervisor.

 

Privacy Compliance Officer:

HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

PREMIER SPORT PSYCHOLOGY, PLLC PLEDGE REGARDING HEALTH INFORMATION

Premier Sport Psychology, PLLC understands that health information about you and your health care is personal. We are committed to protecting health information about you in compliance with the Federal Health Insurance Portability and Accountability Act of 1996 (“HIPPA”), the Minnesota Health Records Act, and other applicable Federal and State laws and administrative regulations. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Premier Sport Psychology, PLLC. This notice will tell you about the ways in which we can use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to:

  • Make sure that Protected Health Information (“PHI”) that identifies you is kept private;
  • Give you this notice of our legal duties and privacy practices with respect to health information;
  • Follow the terms of the notice that is currently in effect;
  • We can change the terms of this notice, and such changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website;

 

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

 

For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization in order to carry out the health care provider’s own treatment, payment or health care operations. We may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard, because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another.

 

Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

 

CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

  1. Psychotherapy Notes. We do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your authorization unless the use or disclosure is:
  2. a)For our use in treating you; b)For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy; c) For our use in defending Premier Sport Psychology PLLC in legal proceedings instituted by you; d) For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA and other applicable laws and regulations; e) Required by law where the use or disclosure is limited to the requirements of such law; f) Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes;  g) Required by a coroner who is performing duties authorized by law; h) Required to help avert a serious threat to the health and safety of others;
  3. Marketing Purposes.We will NOT use or disclose your Protected Health Information (“PHI”) for marketing purposes.
  4. Sale of PHI.We will NOT sell your Protected Health Information (“PHI”).

 

CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION

Subject to certain limitations in the law, we can use and disclose your Protected Health Information (“PHI”) without your authorization for the following reasons:

  1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law;
  2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety;
  3. For health oversight activities, including audits and investigations;
  4. For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain an authorization from you before doing so;
  5. For law enforcement purposes, including reporting crimes occurring on our premises;
  6. To coroners or medical examiners, when such individuals are performing duties authorized by law;
  7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition;
  8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions;
  9. For workers’ compensation purposes. Although our preference is to obtain an authorization from you, we may provide your Protected Health Information (“PHI”) in order to comply with workers’ compensation laws;
  10. Appointment reminders and health related benefits or services. We may use and disclose your Protected Health Information (“PHI”) to contact you to remind you that you have an appointment with us. We may also use and disclose your Protected Health Information (“PHI”) to tell you about treatment alternatives, or other health care services or benefits that we offer.

 

YOU TO HAVE THE RIGHT TO OBJECT TO CERTAIN USES AND DISCLOSURES

You have the right to object to disclosures to family, friends, or others. We may provide your Protected Health Information (“PHI”) to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent or object may be obtained retroactively in emergency situations.

 

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION (“PHI”)

  1. The Right to Request Limits on Uses and Disclosures of Your Protected Health Information (“PHI”).You have the right to ask us not to use or disclose certain Protected Health Information (“PHI”) for treatment, payment, or health care operations purposes. We are not required to agree to your request, and may say “no” if we believe it would affect your health care;
  2. The Right to Choose How We Send Protected Health Information (“PHI”) to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests;
  3. The Right to See and Get Copies of Your Protected Health Information (“PHI”).  You have the right to get an electronic or paper copy of your medical record and other information that we have about you.  Pursuant to Minnesota law, you also have the right to obtain an electronic or paper copy of “psychotherapy notes.” We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost based fee for doing so;
  4. The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your Protected Health Information (“PHI”) for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost based fee for each additional request;
  5. The Right to Correct or Update Your Protected Health Information (“PHI”). If you believe that there is a mistake in your Protected Health Information (“PHI”), or that a piece of important information is missing from your Protected Health Information (“PHI”), you have the right to request that Premier Sport Psychology, PLLC correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request;
  6. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it;
  7. The Right to Authorize Another to Exercise Your Rights on Your Behalf. You have the right to execute a Medical Power of Attorney that authorizes another person to exercise your HIPPA and Minnesota Medical Records Act rights on your behalf.