Organization for Psychoeducational Tutoring

PMB 1056

742 South Meadow Street, Suite 200

Ithaca, NY 14850-5321

Notice Of Privacy Practices

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

This notice describes how health information about you or your child (as a student in this organization) may be used and disclosed and how you can get access to individually identifiable health information.

A. Commitment to your privacy:

We (the Organization for Psychoeducational Tutoring, or OPT) are dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting business, we will create records regarding you or your child, and the services ws provide to you or your child. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and the privacy practices that we maintain concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

The following describes:

• How we may use and disclose your PHI,

• Your privacy rights in your PHI,

• My obligations concerning the use and disclosure of your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by OPT. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that we have created or maintained in the past, and for any of your records that we may create or maintain in the future. You may request a copy of the most current Notice at any time.

B. If you have questions about this Notice, please speak with us about them.

C. We may use and disclose your PHI in the following ways:

The following categories describe the different ways in which we may use and disclose your PHI.

1. Rendering service. We will use your PHI to provide service to your family or your child. For example, for those families whose children are receiving tutoring, we will use the data you give us to decide which areas of tutoring to emphasize the most. The tutor will use your PHI to understand the goals of the tutoring. We may disclose your PHI to health care providers for purposes related to your treatment with them. In the event of urgent need, we will use our judgment about whether to disclose information to health providers without obtaining your written consent; otherwise we will obtain your written consent to disclose information to health care providers.

2. Payment. We will use and disclose your PHI in order to bill and collect payment for the services you may receive from us. We may use your PHI to bill you directly for services and items. Since we are an educational organization and not a health care organization, we do not bill medical insurance or communicate with medical insurance companies.

3. Quality control operations. We may use and disclose your PHI to operate our organization, for example in evaluating the quality of care you received from us.

4. Appointment-related communications. This item has to do with the disclosure inherent in calling or emailing you and leaving messages about possible appointment times. In some circumstances, people do not want others knowing that they are receiving services with us. If there are phone numbers or email addresses that you do NOT want us to leave messages on lest someone else hear or read them, the first choice is not to even give us these. If it is necessary to give me a number or address that is not confidential enough for me to leave messages on, please notify us of that fact at the time you give us the number or address.

5. Disclosures to Family. For students under the age of 18, we will communicate with parents or legal guardians without obtaining written consent, except for the circumstances described in the next paragraph. For students 18 or over, we will ask for your written consent to communicate with parents or legal guardians, or other family members. Students 18 or over have the right to consent or deny such a request.

6. Disclosures to School Personnel or others. We will ask for written consent before communicating with school personnel or other people outside the family. Parents of students under 18 years old, and students 18 years old or over, have the right to consent or to deny such a request.

7. Disclosures required by law. We will use and disclose your PHI when we are required to do so by federal, state or local law. There are many state and federal laws that may require an organization to use and disclose the information they have. If anyone indicates to us an intention to seriously harm another individual, we are ethically required to attempt to protect that threatened individual from harm, for example by contacting that person and warning him or her of the specific threat that we heard, and whom we heard it from. There are times when judges issue court orders requiring service providers to turn over records to courts in the case of custody determinations or other legal proceedings. Thus, a provider who would like to guarantee confidentiality of disclosures in services is NOT legally able to do so.

D. Use and disclosure of your PHI in certain special circumstances:

The following categories describe scenarios in which we may be required to use or disclose your identifiable health information:

1. Public health risks. We may disclose your PHI to public health authorities that are authorized by law to collect information. Some examples of this sort of disclosure (almost all of which will apply to us very seldom if ever) are as follows:

• Reporting child abuse or neglect,

• Preventing or controlling disease, injury or disability,

• Notifying a person regarding potential exposure to a communicable disease,

• Notifying a person regarding a potential risk for spreading or contracting a disease or condition,

• Notifying individuals if a product or device they may be using has been recalled,

2. Health oversight activities. We may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and similar proceedings. We may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. Under certain circumstances we may be required to disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in a dispute.

Our organization certainly does not take on the job of gathering and processing information regarding forensic proceedings, for example custody proceedings. We will make efforts NOT to communicate directly or indirectly with lawyers or judges or courts or court-appointed evaluators when legal disputes between parents arise, such as custody disputes. We would like for parents not to begin tutoring with us unless they agree that we should not be involved in any way in custody disputes.

4. Law enforcement. We may release PHI if asked to do so by a law enforcement official:

• Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement,

• Concerning a death we believe has resulted from criminal conduct,

• Regarding criminal conduct at our offices,

• In response to a warrant, summons, court order, subpoena or similar legal process,

• To identify/locate a suspect, material witness, fugitive or missing person,

• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).

5. Research. We believe that the data stored in our records should not be wasted, but should be analyzed to its maximum potential for helping future students as well as present students. An Institutional Review Board has approved a protocol for our use of students’ and families' PHI in observational research. Parents may permit us to do this if and only if they consent to such research using a separate consent process and consent form. You are not consenting to this research by signing this HIPAA privacy statement; allowing such research is a separate decision.

6. Serious threats to health or safety. We may use and disclose your PHI when necessary to reduce or prevent a serious threat to your or your child’s health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

E. Your rights regarding your PHI:

You have the following rights regarding the PHI that we maintain about you:

1. Confidential communications. You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to us, specifying the requested method of contact, or the location where you wish to be contacted. We will accommodate reasonable requests. You do not need to give a reason for your request.

Email is a very convenient method of communication, but regular email is not a secure method for keeping information confidential. Email communication with teachers about child or adolescent students is a boon to decision-making and research; but again, the confidentiality of email is not able to be assured. For confidential information, one option is encrypting information into a password-protected file, sending the file as an attachment to email, and sending the password to the recipient of the message, via phone. The disadvantage of this is that the extra amount of effort required to do this interferes with the ease of communication. We will try to abide by your decision regarding the benefit/risk ratio for email communication.

2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your or your child’s PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to us. Your request must describe in a clear and concise fashion:

• The information you wish restricted,

• Whether you are requesting to limit our use, disclosure or both,

• To whom you want the limits to apply.

3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including our records and billing records. You must submit your request in writing to us in order to inspect and/or obtain a copy of your PHI. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. WE may deny your request to inspect and/or copy in certain limited circumstances.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to us. You must provide us with a reason that supports your request for amendment. We will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask me to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the organization; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our organization, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of disclosures. All of our students' families have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our organization has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine services in our organization is not required to be documented – for example, using your information to check payment records. In order to obtain an accounting of disclosures, you must submit your request in writing. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003.

6. Right to a paper copy of this notice. You are entitled to receive a paper copy of this notice of privacy practices. You may ask us to give you a copy of this notice at any time.

7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with me or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to provide an authorization for other uses and disclosures. We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to usregarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your

authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.

Again, if you have any questions regarding this notice of health information privacy policies, please speak with us about them.

Please initial the following, if you agree:

1. OPT personnel should not be asked to take a role in custody determinations. ____________

2. My preference regarding email is (please check one):

______a. Let the ordinary password protection be enough protection and use email as is convenient.

______b. Use email only to send encrypted files as attachments.

______c. Not use email at all.

4. If you have given me any phone numbers or addresses that you do not want us to use because of confidentiality, please write them below, or write any other requests for confidential communication.

Your printed name:________________________________________________________

Today’s date: ____________________________________________________________

Your signature: ___________________________________________________________