Notice of Privacy Practices




This section describes the 2013 Health Insurance Portability and Accountability Act (HIPAA) which sets standards for the security of information related to your health and health care. SCPS may revise this Notice in the future to reflect changes in the law or their understanding of it. The revised Notice will apply to all information SCPS has or will have about your treatment. The revised Notice will be posted in the waiting room and copies will be available at your request. You can also contact your psychologist to request a copy be mailed to you. SCPS is committed to maintaining your privacy and confidentiality within the limits required by your treatment, payment for your treatment, operation of this psychological practice, your safety, the safety of others, and the law.

Please note that the Informed Consent, is based on Pennsylvania Psychology Law and is, in most cases, stricter than, and supercedes the HIPAA laws as described below.


Protected Health Information (PHI):  information about your treatment or planned treatment that is identifiable as yours. This information may be in written, electronic, or verbal form. Examples include your presence in treatment, visits, financial information, assessment and testing, diagnosis, treatment plan, discharge summary, and psychotherapy notes. Psychotherapy notes include what you talk about in individual, group, couple, or family sessions. They have stronger privacy protection than other PHI, as discussed in this Notice.

Consent: your signed agreement to be treated and to the conditions of being treated by your psychologist. If you do not give your consent, you cannot be treated. Consent includes limited use and disclosure of your PHI for three purposes: treatment, payment for services, and operation of SCPS.

Authorization: your signed agreement to disclose specified PHI to a specified person or organization, for specified purposes and for a specified time period. You can revoke an authorization at any time (in writing), and no further disclosures will be made. If you are under 14, your parent(s) or legal guardian(s) must sign any authorization for you and have the right to know about your treatment. Authorization is not required for treatment.

Use of PHI: when your information is shared, applied, utilized, examined, or analyzed within this psychological practice.

Disclosure of PHI: when information is released, transferred, provided or otherwise revealed to a third party outside of this practice. With some exceptions, SCPS may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, SCPS is always legally required to follow the privacy practices described in this Notice.



Use of PHI: SCPS uses your PHI to provide psychotherapy treatment to you. Examples include developing treatment plans, reviewing notes, and evaluating progress.

Disclosure of PHI: Your consent is not required if you need emergency treatment provided that your psychologist attempts to get your consent after this treatment is rendered. In the event that your psychologist tries to get your consent but you are unable to communicate (for example, if you are unconscious or in severe pain) and your psychologist believes that you would consent to such treatment if you could, they might disclose your PHI.

In all other cases, your written authorization is required whenever your psychologist wishes to disclose your PHI to another person or organization for the purpose of treatment. Psychotherapy notes are only released with your specific authorization for the purpose of treatment.


Use of PHI: Your PHI is used to determine eligibility for reimbursement by your health insurance, to calculate balances of payments owed by you or your health insurance, and to decide whether collection activity is needed on your account. Only the minimum information about your treatment is necessary for these tasks, usually type of treatment provided, dates of treatment and diagnosis. SCPS could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for this office.

Disclosure of PHI: When you decide to use your health insurance to help pay for your treatment with SCPS, you are also agreeing to let SCPS disclose information about your treatment that is routinely requested by your health insurance plan to verify that treatment is occurring and that it is needed. This information may range from dates of treatment and type of treatment provided to diagnosis, treatment plan, and anticipated outcome of treatment. Occasionally treatment records are audited; in these cases identifying information is removed from your PHI. If financially possible, you may choose to pay for treatment yourself in order to avoid such disclosures.


Use of PHI: In order to help this psychological practice to function well, your PHI is used to schedule appointments and other routine functions. Your PHI may be used administratively to review the quality of treatment provided, such as average days between first contact and first appointment. SCPS may also provide your PHI to their attorneys, accountants, consultants, and others to make sure that they are in compliance with applicable laws.

Disclosure of PHI: Your first name may be spoken when your psychologist greets you in the waiting area. The scheduling and confirmation of appointments is done by phone, e-mail and/or text, and your psychologist will be discreet if ever speaking with a third party. Please inform your psychologist of any phone numbers (or e-mail addresses) where you do not want to be contacted or do not wish to have a message left with a third party.


Some disclosures of PHI are required by law with or without your consent or authorization. SCPS would discuss any such disclosure with you.

●      Child Abuse: whenever SCPS reasonably suspects that a child with whom they have had direct contact has been the victim of abuse or neglect, they must immediately report such to a State-wide hotline, which forwards the information to the local Child and Youth Services. If there appears to be imminent danger, SCPS will also be required to contact the police. In addition, if SCPS reasonably suspects that a child with whom they have direct contact has experienced mental suffering or emotional abuse, your psychologist may report it.

●      Adult Abuse: if SCPS reasonably suspects an elder or dependent adult with whom they have direct contact has been the victim of abuse or neglect, they must report the suspected abuse or neglect immediately to the elder abuse hotline or the local Area Agency on Aging.

●      Health Oversight: if a complaint is filed against your psychologist with the professional Board, the Board has the authority to subpoena confidential mental health information relevant to that complaint. In addition, if the U.S. Secretary of Health and Human Services is asked by a client to investigate or assess SCPS’s compliance with HIPAA regulations, they also can subpoena records. This may include psychotherapy notes.

●      Judicial or Administrative Proceedings: if you are involved in a court proceeding and there is a court order for information about your treatment, SCPS must provide that information. This may include psychotherapy notes. A subpoena does not necessarily require disclosure and your psychologist will discuss the situation with you.

●      Serious Threat to Health or Safety: if you disclose to SCPS a serious threat of physical violence against an identifiable victim, they must make reasonable efforts to communicate that information to the potential victim and the police. If they have reason to believe that you are dangerous to yourself or others, SCPS may release relevant information as necessary to prevent the threatened danger and/or to help you access a higher level of care, such as hospitalization.

●      Driving Risk: Pennsylvania law specifically requires that healthcare providers report concern about an individual’s ability to operate a motor vehicle safely to the medical department of the Pennsylvania Department of Transportation.


All other disclosures of your PHI require your written authorization. SCPS will limit the information to that necessary to accomplish the purpose of the disclosure, and if non-identifying information can be used, SCPS will do so. Such disclosures for purposes other than treatment will not include psychotherapy notes. Examples include:

●      To law enforcement officials to prevent, investigate, or prosecute a crime, or to locate a suspect, fugitive, missing person, or material witness.

●      To a public health organization about a communicable disease or adverse drug incident.

●      To a government agency about a threat to national security or other intelligence.

●      To your employer, military authorities, or a correctional facility.

●      Related to a worker’s compensation claim filed by you.


●      Right to request restrictions: you have the right to request (in writing) a restriction on use or disclosure of any part of your PHI for the purposes of treatment, payment, or healthcare operations. A request may be denied (in writing) if SCPS believes that the restriction would not allow them to perform any of these functions. This does not apply to disclosures requiring your written authorization.

●      Right to inspect and copy: you have the right to inspect and receive a copy of your PHI except for psychotherapy notes, information compiled in anticipation of a criminal, civil, or administrative action, and any PHI to which access is restricted by law. SCPS may choose to review this information with you to assist you in understanding it. Please understand that older records may be destroyed, and therefore no longer available, in accordance with applicable law or standards. If you ask for copies of your PHI, there will be a charge of not more than $.25 per page.

●      Right to amend: if you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that a correction be made to the existing information or an addition be made for the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of the receipt of your request. SCPS may deny your request, in writing, if SCPS finds that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of their records, or (d) written by someone other than SCPS. The denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and SCPS’s denial be attached to any future disclosures of your PHI. If your request is approved, SCPS will make the change(s) to your PHI. Additionally, SCPS will tell you that the changes have been made, and will advise all others who need to know about the change(s) to your PHI.

●      Right to receive confidential communication by alternative means and at alternative locations: it is your right to ask that your PHI be sent to you at an alternate address. For example - sending information to your work address rather than your home address; or, sending information via e-mail instead of by regular mail. SCPS is obliged to agree to your request providing that they can give you the PHI, in the format that you requested, without undue inconvenience.

●      Right to an accounting:  you have to right to receive within 60 days of your written request an accounting of any disclosures made of your PHI that: (a) occurred after April 14, 2003; (b) happened within the last six years; (c) were made without a written authorization; (d) were not for the purposes of treatment, payment, or healthcare operations; (e) were not for national security or intelligence purposes; (f) were not made to law enforcement or health oversight officials who requested in writing a delay of accounting in order to carry out their mandated activities.

●      Right to restrict disclosures associated with out of pocket payment: you have the right to restrict certain disclosures of PHI to health plans or insurance companies if you pay out-of-pocket in full for services.

●      Right of notification: you have the right to be notified following a breach of unsecured protected health information.

●      Right to file a complaint: you have the right to file a complaint if you believe your PHI has been inappropriately disclosed. You may speak with your psychologist in person or by phone. Their contact information is available on the SCPS website ( You can also call the Secretary of Health and Human Services at U.S. Department of Health and Human Services, Office of Civil Rights at (877) 696-6775. You can send complaints in writing to Privacy Complaints, P. O. Box 8050, U. S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. You will not be punished in any manner and treatment will not be withheld if you make a complaint.

●      Right to be notified of a PHI breach: in the case of a breach, SCPS is required to notify each affected individual whose unsecured PHI has been compromised. Even if such a breach was caused by a business associate (e.g., insurance company), SCPS is ultimately responsible for providing the notification directly or via the business associate.  SCPS bears the ultimate burden of proof to demonstrate that all notifications were given or that the impermissible use or disclosure of PHI did not constitute a breach and must maintain supporting documentation, including documentation pertaining to the risk assessment.

By signing this, I acknowledge that I have read and understood the entirety of this document and agree to abide by its terms during my professional relationship with SCPS. This document is also available in a downloadable form by clicking below. In addition, upon request, your psychologist can provide you a paper copy.



Use the link below to open the above Notice of Privacy Practices as a Word document.