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Updated Notice of Policies and Practices
to Protect the Privacy of Your Health Information,
Updated November 19, 2018
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. IT CONTAINS SUMMARY INFORMATION ABOUT THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA), A FEDERAL LAW THAT PROVIDES PRIVACY PROTECTIONS AND PATIENT RIGHTS WITH REGARD TO THE USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION (PHI) USED FOR THE PURPOSE OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
Alison Dickson may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes. To help clarify these terms, here are some definitions:
•“PHI” refers to information in your health record that could identify you such as your name, date of birth, phone number, or address.
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Treatment, Payment and Health Care Operations”– Treatment is when Alison Dickson provides, coordinates or manages your therapy or assessment and other related services. In addition to direct services, this might include such things as consultation with another health care provider, such as your family physician or another psychologist. Payment is when Alison Dickson obtains reimbursement for your healthcare, either directly from you or from a third party. Health Care Operations are activities that relate to the performance and operation of the practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and care coordination.
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•“Use” applies only to activities within the practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
•“Disclosure” applies to activities outside of Alison Dickson Counseling, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
Alison Dickson may use or disclose PHI for purposes outside of treatment, payment, and healthcare operations as provided below or 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 Alison Dickson is asked for information for purposes outside of treatment, payment and health care operations, an authorization from you will be obtained before releasing this information. You may cancel all such authorizations at any time, provided each cancellation is in writing. Cancellation of an authorization does not apply to the information that has already been released.
III. Uses and Disclosures with Neither Consent nor Authorization
PHI may be disclosed without your consent or authorization in the following circumstances:
• Child Abuse:
If there is cause to believe that a child has been, or may be, abused, neglected, sexually abused, or exploited Alison Dickson is legally mandated to make a report of such to the Abuse Hotline operated by the Florida department of Children and Families. THIS INCLUDES CHILDREN WITNESSING ACTS OF DOMESTIC VIOLENCE.
• Abuse of a Vulnerable Adult:
If there is cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, Alison Dickson is legally mandated to make a report of such to the Abuse Hotline operated by the Florida department of Children and Families.
• Health Oversight:
If a complaint is filed against Alison Dickson with the State Department of Health or Board of Psychology, the Board has the authority to subpoena confidential mental health information relevant to that complaint and Alison Dickson is required to respond to the subpoena.
• Judicial or Administrative Proceedings:
If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged (protected)
under state law, and will not be released without written authorization from you or your personal or legally appointed representative, or a court order. The privilege (protection) does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
• Serious Threat to Health or Safety:
If it is determined that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, relevant confidential mental health information may be released to medical or law enforcement personnel.
• Worker’s Compensation: If you file a worker's compensation claim, records relating to your diagnosis and treatment may be disclosed to your employer, employer’s insurance carrier, and/or their attorneys.
IV. Patient's Rights and Provider'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, Alison Dickson is not required to agree to a restriction 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 being seen at Alison Dickson Counseling. Upon your request, any communications may be to another address.)
• Right to Inspect and Copy
You have the right to inspect or obtain a copy (or both) of PHI in Alison Dickson Counseling’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. There may be a small charge for copying a record. Your access to PHI may be denied under certain circumstances, but in some cases you may have this decision reviewed. On your request, Alison Dickson will discuss with you the details of the request and review 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. Your request may be denied, but this is also subject to review. On your request, Alison Dickson 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 for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, Alison Dickson 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 this notice.
Provider’s Duties:
•Alison Dickson 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 , and to notify
you in the event your PHI is breached.
Alison Dickson Counseling reserves the right to change the privacy policies and practices described in this notice. However, unless you are provided with the updated notice, Alison Dickson is required to abide by the notice currently in effect.
V. Complaints
If you are concerned that Alison Dickson has violated your privacy rights, or you disagree with a decision regarding access to your records, you may contact The Florida Department of Health Division of Medical Quality Assurance (850-245-4339 or http://www.floridahealth.gov/ ). You may also send a complaint to the Secretary of the U.S. Department of Health and Human Services, 1-877-696-6775. The person or agency listed above can provide you with the appropriate address upon request. You will not be retaliated against for filing a complaint.
VI. Restrictions and Changes to Privacy Policy
Alison Dickson reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that is maintained. You will be provided with a revised notice in person or by mail (or email if appropriate) prior to the revisions taking effect
COLORADO DISCLOSURE STATEMENT
1. INFORMATION Alison Dickson, MS, LMFT
Alison Dickson Counseling, PLLC 73 White Bridge Pike
STE 103 #161, Nashville, TN 37015
2. CREDENTIALS Licensure:
Marriage and Family Therapist MFT.0001711, State of Colorado
Marriage and Family Therapist MT3599, State of Florida
Marriage and Family Therapist MFT2122, State of Tennessee
Degrees: Master of Science, Counseling Psychology: Mount Saint Mary’s University
Los Angeles California 2015 Professional Experience:
I have completed my state-mandated two years of post- masters supervision and am fully licensed as a Marriage and Family Therapist in Colorado, Florida and Tennessee. I have worked in the private and nonprofit sector, with foster families, addiction, couples, veterans, eating disorders, anxiety, trauma, caretaker burnout, disabilities, athletes, crisis of faith, grief, divorce, self-esteem, infertility, separation, relationship communication and stress, career counseling, anger management, premarital counseling, pet grief, emotional support animals, infidelity, weight-related issues, life transitions.
Certifications: Eating Disorder Intuitive Therapy (EDIT) Certified Clinician Trauma-Focused Cognitive Behavioral Therapy Certified Clinician
3. REGULATION OF PSYCHOTHERAPISTS The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The regulatory boards can be reached at 1560 Broadway, Suite 1350, Denver, CO 80202, 303.894-7800. The regulatory requirements for mental health professionals provide that a Licensed Clinical Social Worker, a Licensed Marriage and Family therapist, and a Licensed Professional Counselor must hold a masters degree in their profession and have two years of post-masters supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post- doctorial supervision. A Licensed Social Worker must hold a master’s degree in social work. A Psychologist Candidate, a Marriage and Family Therapist
Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. A Certified Addiction Counselor I (CAC I) must be a high school graduate, and complete required training hours and 1000 hours of supervised experience. A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must have a bachelor’s degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master’s degree and meet the CAC III requirements. A Registered Psychotherapist is listed in the State’s Database and is authorized by law to practice psychotherapy in Colorado, but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state.
4. CLIENT RIGHTS AND IMPORTANT INFORMATION
You are entitled to receive information from me about my methods of therapy, the techniques I use, and the duration of your therapy, and my fee. Please ask if you would like to receive this information.
You can seek a second opinion from another therapist or terminate therapy at any time.
In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the Board that licenses, certifies or registers the therapist.
Generally speaking, information provided by and to a client in a professional relationship with a psychotherapist is legally confidential, and the therapist cannot disclose the information without the client’s consent. There are several exceptions to confidentiality which include: (1) I am required to report any suspected incident of child abuse or neglect to law enforcement; (2) I am required to report any threat of imminent physical harm by a client to law enforcement and to the person(s) threatened; (3) I am required to initiate a mental health evaluation of a client who is imminently dangerous to self or to others, or who is gravely disabled, as a result of a mental disorder; (4) I am required to report any suspected threat to national security to federal officials; (5) I am required to report abuse of an elder, who is 70 years of age or older, and also abuse of an at- risk adult with an Intellectual Developmental Disability (IDD), which I believe has probably occurred, including institutional neglect, physical injury, financial exploitation, or unreasonable restraint; and (6) I may be required by Court Order to disclose treatment information.
When I am concerned about a client’s safety, it is my policy to request a Welfare Check through local law enforcement. In doing so, I may disclose to law enforcement officers information concerning my concerns. By signing this Disclosure Statement and agreeing to treat with me, you consent to this practice, if it should become necessary.
Under Colorado law, C.R.S. § 14-10-123.8, parents have the right to access mental health treatment information concerning their minor children, unless the court has restricted access to such information. If you request treatment information from me, I may provide you with a treatment summary, in compliance with Colorado law and HIPAA Standards.
I agree not to record our sessions without your written consent; and you agree not to tape record a session or a conversation with me without my written consent.
5. DISCLOSURE REGARDING DIVORCE AND CUSTODY LITIGATION
If you are involved in divorce or custody litigation, my role as a therapist is not to make recommendations to the court concerning custody or parenting issues. By signing this Disclosure Statement, you agree not to subpoena me to court for testimony or for disclosure of treatment information in such litigation; and you agree not to request that I write any reports to the court or to your attorney, making recommendations concerning custody. .
6. CLIENT RECORD RETENTION POLICY My records regarding the treatment of adults will be kept for 7 years after
treatment ends or following our last session, but I may
not retain them after 7 years. My records for treatment
of minors will be kept for 7 years, beginning on the last
date of treatment or for 7 years beginning on the date
when the minor turns 18 years of age, whichever is
later. In no event am I required to keep these records
longer than 12 years.
Alison Dickson, MS, LMFT
3599 (Florida)
MFT.0001711 (Colorado)
MFT2122 (Tennessee)
Alison Dickson Counseling, PLLC