CHAMPION PSYCHOLOGICAL SERVICES, LLC

P.O. Box 2623 Mercerville, NJ 08619

Carmen Lynn Hodges, Psy.D., LCADC

New Jersey Licensed Psychologist #35SI0049600

New Jersey Licensed Clinical Alcohol & Drug Counselor #37LC0006900

HIPAA 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 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 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 health care 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, clinic, practice group, etc.] 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 obtain an authorization from you before using or disclosing PHI in a way that is not described in this Notice.

You may revoke all such authorizations 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 to believe that a child has been subject to abuse, I must report this immediately to Child Protection and Permanency (formerly called the New Jersey Division of Youth and Family Services).

• Adult and Domestic Abuse: If I reasonably believe that a vulnerable adult is the subject of abuse, neglect, or exploitation, I may report the information to the county adult protective services provider.

• Health Oversight: If the New Jersey State Board of Psychological Examiners issues a subpoena, I may be compelled to testify before the Board and produce your relevant records and papers.

• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is privileged under state law, and I must not release this information without written authorization from you or your legally appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. I must inform you in advance if this is the case.

• Serious Threat to Health or Safety: If you communicate to me a threat of imminent serious physical violence against a readily identifiable victim or yourself and I believe you intend to carry out that threat, I must take steps to warn and protect. I also must take such steps if I believe you intend to carry out such violence, even if you have not made a specific verbal threat. The steps I take to warn and protect may include arranging for you to be admitted to a psychiatric unit of a hospital or other health care facility, advising the police of your threat and the identity of the intended victim, warning the intended victim or his or her parents if the intended victim is under 18, and warning your parents if you are under 18.

• Worker’s Compensation: If you file a worker’s compensation claim, I may be required to release relevant information from your mental health records to a participant in the worker’s compensation case, a reinsurer, the health care provider, medical and non-medical experts in connection with the case, the Division of Worker’s Compensation, or the Compensation Rating and Inspection Bureau.

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.