103 Forrest Crossing Blvd, Suite 201B
Franklin, TN 37064
HIPAA Notice
Clinicians’ Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL, MEDICAL, AND OTHER HEALTH-RELATED 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
Your use of the Website is also subject to YBLT’s Privacy Policy. Please review our Privacy Policy, which also governs the Website and informs users of our data collection practices. Your agreement to the Privacy Policy is hereby incorporated into these Terms.
Red Deer Sleep and Health Psychology, PLLC (hereafter, Red Deer) clinicians and their support staff 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.
“Clinician” refers to any mental health professional who provides clinical services. At Red Deer this currently includes psychologists.
“Treatment, Payment and Health Care Operations”
Treatment is when your Red Deer clinician provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when the clinician consults with another health care provider, such as your family physician (PCP) or another mental health professional.
Payment is when Red Deer obtains reimbursement for your healthcare. For payment, we may use your information to bill you, your insurance, Employee Assistance Plan (EAP) or others, so we can be paid for the treatments we provide to you. We may contact your insurance company or EAP to find out exactly what your plan covers. We may have to tell them about your diagnoses, what treatments you have received, and the changes we expect in your conditions. We will need to tell them about when we met, your progress, and other similar things.
Health Care Operations are activities that relate to the performance and operation of Red Deer’s office practices. 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 Red Deer such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of Red Deer such as releasing, transferring, or providing access to information about you to other parties.
“Consent” means that you give prior permission. You give Red Deer consent to handle your PHI as outlined in this Notice when you sign the Patient Acknowledgement form.
In this office, your PHI is likely to include these kinds of information:
We use PHI for many purposes. For example, we may use it:
Red Deer Sleep and Health Psychology, PLLC (hereafter, Red Deer) clinicians and their support staff 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.
“Clinician” refers to any mental health professional who provides clinical services. At Red Deer this currently includes psychologists.
“Treatment, Payment and Health Care Operations”
Treatment is when your Red Deer clinician provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when the clinician consults with another health care provider, such as your family physician (PCP) or another mental health professional.
Payment is when Red Deer obtains reimbursement for your healthcare. For payment, we may use your information to bill you, your insurance, Employee Assistance Plan (EAP) or others, so we can be paid for the treatments we provide to you. We may contact your insurance company or EAP to find out exactly what your plan covers. We may have to tell them about your diagnoses, what treatments you have received, and the changes we expect in your conditions. We will need to tell them about when we met, your progress, and other similar things.
Health Care Operations are activities that relate to the performance and operation of Red Deer’s office practices. 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 Red Deer such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of Red Deer such as releasing, transferring, or providing access to information about you to other parties.
“Consent” means that you give prior permission. You give Red Deer consent to handle your PHI as outlined in this Notice when you sign the Patient Acknowledgement form.
In this office, your PHI is likely to include these kinds of information:
- Your history: Things that happened to you as a child; your school and work experiences; your marriage and other personal history.
- Reasons you came for treatment: Your problems, complaints, symptoms, or needs.
- Diagnoses: These are the medical terms for your problems or symptoms.
- A treatment plan: This is a list of the treatments and other services that we think will best help you.
- Progress notes: Each time you come in, we write down some things about how you are doing, what we notice about you, and what you tell us.
- Records we get from others who treated you or evaluated you.
- Psychological test scores, school records, and other reports.
- Information about medications you took or are taking.
- Legal matters.
- Billing and insurance information
- There may also be other kinds of information that go into your health care records here.
We use PHI for many purposes. For example, we may use it:
- To plan your care and treatment.
- To decide how well our treatments are working for you.
- When we talk with other health care professionals who are also treating you, such as your family physician (PCP) or the professional who referred you to us.
- To show that you actually received services from us, which we billed to you or to your health insurance company.
II. Uses and Disclosures Requiring Authorization
Your Red Deer clinician 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 instances when your clinician is asked for information for purposes outside of treatment, payment and health care operations, the clinician will obtain an authorization from you before releasing this information.
The clinician will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes the clinician has made about conversations with you during a private, group, joint, or family counseling session, which have been kept separate from the rest of your medical 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) the clinician has 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.
The clinician will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes the clinician has made about conversations with you during a private, group, joint, or family counseling session, which have been kept separate from the rest of your medical 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) the clinician has 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
Your Red Deer clinician may use or disclose PHI without your consent or authorization in the following circumstances:
- Child abuse: If the clinician has knowledge of any child who is suffering from or has sustained any wound, injury, or disability, or physical or mental condition of such a nature as to reasonably indicate that it has been caused by brutality, abuse, or neglect, the clinician is required by law to report such harm immediately to Tennessee Child Protective Services or to the judge having juvenile jurisdiction, or to the office of the sheriff or the chief law enforcement official of the municipality where the child resides. If the clinician has reasonable cause to suspect that a child has been sexually abused, the clinician must report such information, regardless of whether the child has sustained any injury. Also, if the clinician learns that a person under eighteen (18) years of age witnesses abuse of another child in the person's family or household, or domestic abuse, as defined in §36-3-601, of someone in the family or household.
- Adult and domestic abuse: If the clinician has reasonable cause to suspect that an adult who is vulnerable physically, mentally, or emotionally has suffered abuse, neglect, or exploitation, the clinician is required by law to report such information to the Tennessee Department of Human Services.
- Health oversight: If a complaint is filed against the clinician with the Tennessee Board of Examiners in Psychology (or other appropriate state Board of Examiners), the Board has the authority to subpoena confidential mental health information from me relevant to that complaint.
- Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that a Red Deer clinician has provided you and/or the records thereof, such information is privileged under state law, and the clinician must not release this information without your written authorization 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. The Red Deer clinician must inform you in advance if this is the case.
- Serious threat to health or safety: If you communicate to your clinician an actual threat of bodily harm against a clearly identified victim, and the clinician has determined or reasonably should have determined that you have the apparent ability to commit such an act and are likely to carry out the threat unless prevented from doing so, the clinician is required to take reasonable care to predict, warn of, or take precautions to protect the identified victim from your violent behavior.
- Client’s threat to harm self: If a client is deemed to be an immediate threat of harm to self, the Red Deer psychologist may be obligated to seek hospitalization for him/her, or to contact family members or others (including law enforcement) who can help provide protection.
- Workers' compensation: If you file a worker's compensation claim, and the clinician is seeing you for treatment relevant to that claim, the clinician must, upon request, furnish to your employer or insurer, and to you, a complete report as to the claimed injury, the effect upon you, the prescribed treatment, and estimate of duration of treatment, if any, and a statement of charges.
- Red Deer providers are authorized by PSYPACT (Psychology Interjurisdictional Compact), which allows licensed psychologists to provide therapy across state lines through secure telehealth platforms. The laws of the state the client is located in governs confidentiality and privilege.
IV. Patient's Rights and Clinician’s Duties
Patient’s Rights:
Clinician’s Duties:
- Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of PHI about you. However, the Red Deer clinician is not required to agree to a restriction that 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 a clinician. Upon your request, your bills will be sent to another address.)
- Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in Red Deer’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, the Red Deer clinician will discuss with you the details of the request 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. The clinician may deny your request. On your request, the clinician 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 regarding you. On your request, the clinician 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 Red Deer upon request, even if you have agreed to receive the notice electronically.
Clinician’s Duties:
- Red Deer is required by law to maintain the privacy of PHI and to provide you with a notice of its legal duties and privacy practices with respect to PHI.
- Red Deer reserves the right to change the privacy policies and practices described in this notice. Unless Red Deer notifies you of such changes, however, Red Deer is required to abide by the terms currently in effect.
- If Red Deer revises its policies and procedures, Red Deer will notify you by mail, phone, fax, or e-mail.
IV. Patient's Rights and Clinician’s Duties
Patient’s Rights:
Clinician’s Duties:
- Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of PHI about you. However, the Red Deer clinician is not required to agree to a restriction that 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 a clinician. Upon your request, your bills will be sent to another address.)
- Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in Red Deer’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, the Red Deer clinician will discuss with you the details of the request 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. The clinician may deny your request. On your request, the clinician 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 regarding you. On your request, the clinician 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 Red Deer upon request, even if you have agreed to receive the notice electronically.
Clinician’s Duties:
- Red Deer is required by law to maintain the privacy of PHI and to provide you with a notice of its legal duties and privacy practices with respect to PHI.
- Red Deer reserves the right to change the privacy policies and practices described in this notice. Unless Red Deer notifies you of such changes, however, Red Deer is required to abide by the terms currently in effect.
- If Red Deer revises its policies and procedures, Red Deer will notify you by mail, phone, fax, or e-mail.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision a Red Deer makes about access to your records, or have other concerns about your privacy rights, you may contact the Red Deer Privacy Officer, Dr. Skyler Shollenbarger at 931-219-9778, ext. 1.
If you believe that your privacy rights have been violated and wish to file a complaint with Red Deer’s office, you may send your written complaint to Dr. Skyler Shollenbarger, 103 Forrest Crossing Blvd. Suite 201B, Franklin, TN. 37064. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Red Deer’s Privacy Officer can provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. Red Deer will not retaliate against you for exercising your right to file a complaint.
If you believe that your privacy rights have been violated and wish to file a complaint with Red Deer’s office, you may send your written complaint to Dr. Skyler Shollenbarger, 103 Forrest Crossing Blvd. Suite 201B, Franklin, TN. 37064. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Red Deer’s Privacy Officer can provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. Red Deer will not retaliate against you for exercising your right to file a complaint.
VII. Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information.
VI. Effective Date and Changes to Privacy Policy
This notice will go into effect on June 21, 2024.
Red Deer reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI maintained by Red Deer. Red Deer will notify you by mail, phone, fax, or e-mail of the revision of notice and make the revised notice available any of its offices. If needed, Red Deer will also provide a revised notice by mail, e-mail, or fax. Additionally, the notice will be made available on Red Deer’s website, www.reddeerpsych.com.
Red Deer reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI maintained by Red Deer. Red Deer will notify you by mail, phone, fax, or e-mail of the revision of notice and make the revised notice available any of its offices. If needed, Red Deer will also provide a revised notice by mail, e-mail, or fax. Additionally, the notice will be made available on Red Deer’s website, www.reddeerpsych.com.