• “Use” applies only to activities within Jeff Miller, PhD., such as sharing, employing, applying, utilizing, examining, and
analyzing information that identifies you.
• “Disclosure” applies to activities outside of Jeff Miller, PhD., such as releasing, transferring, or providing access to
information about you to other parties.
II. Uses and Disclosures Requiring Authorization
Jeff Miller, PhD. 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 we are asked for information for purposes outside of
treatment, payment or health care operations, Jeff Miller, PhD. will obtain an authorization from you before releasing this
information. If your psychologist keeps “psychotherapy notes,” we will
also need to obtain an authorization before releasing your psychotherapy
notes. “Psychotherapy notes” are notes about your conversation during a
private, group, or joint counseling session, which are kept separate from
the rest of your Jeff Miller, PhD. file. These notes
are given a greater degree of protection than PHI. The psychologist you
work with may or may not keep separate “psychotherapy notes” as defined
here. Your psychologist will discuss this with you.
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) Jeff Miller, PhD. 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
Jeff Miller, PhD. 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, Jeff Miller, PhD. must immediately report such information to
the Missouri Division of Family Services. Jeff Miller, PhD. must also report sexual abuse or molestation of a child under 18 years
of age to Family Services. Jeff Miller, PhD. may also
report child abuse or neglect to a law enforcement agency or juvenile
• 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, Jeff Miller, PhD.
must report such information to the Missouri Department of Social
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 Jeff Miller, PhD. relevant to disciplinary
proceedings and investigations conducted by the Missouri State Committee
• 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
Jeff Miller, PhD. 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.
• 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, Jeff Miller, PhD. must disclose your relevant confidential
information to the appropriate professional workers, public authorities,
the potential victim, his or her family, or your family.
Compensation – If you file a worker’s compensation claim, Jeff Miller, PhD. 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. Your Rights and Psychologist's Duties
• Right to Request
Restrictions – You have the right to request restrictions on certain uses
and disclosures of protected health information. However, Jeff Miller, PhD. is not required to agree to a restriction you
• 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 at Jeff Miller, PhD.. 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 Jeff Miller, PhD. mental
health and billing records used to make decisions about you for as long as
the PHI is maintained in the record. Jeff Miller, PhD.
may deny your access to PHI under certain circumstances, but in some
cases, you may have this decision reviewed. On your request, a
psychologist will discuss with you the details of the request and denial
• Right to Amend – You have the right to request an amendment of PHI for
as long as the PHI is maintained in the record. Jeff Miller, PhD. may deny your request. On your request, a psychologist 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, a psychologist 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
Privacy Notice from Jeff Miller, PhD. upon request.
• Jeff Miller, PhD. is 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.
• Jeff Miller, PhD. reserves the right to change the
privacy policies and practices described in this notice. Unless Jeff Miller, PhD. notifies you of such changes, however,
Jeff Miller, PhD. is required to abide by the terms
currently in effect.
• If Jeff Miller, PhD. revises our policies and
procedures, we will provide you with a revised notice at your next
appointment or send it to you by mail.
If you are
concerned that Jeff Miller, PhD. has violated your privacy rights, or you
disagree with a decision Jeff Miller, PhD. made about access to your
records, you may contact Jeff Miller, PhD.at (816) 224-6500.
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.
This notice will
go into effect on April 14th, 2003.
Jeff Miller, PhD. reserves the right to change the terms of this
notice and to make the new notice provisions effective for all PHI that we
maintain. If Jeff Miller, PhD. revises this notice, we
will provide you with a revised notice at your next appointment or send it
to you by mail.