THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

BSI 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.

• "Treatment, Payment and Health Care Operations"

• "Use" applies only to activities within the BSI practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• "Disclosure" applies to activities outside of the BSI practice such as releasing, transferring, or providing access to information about you to other parties.

A BSI 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 those instances when a BSI clinician asks for information for purposes outside of treatment, payment and health care operations,  BSI will obtain an authorization from you before releasing this information.  BSI will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes a BSI clinician has made about our conversation during a private, group, joint, or family counseling session, which BSI have 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) BSI 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.

BSI may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If BSI has reasonable cause to suspect that a child seen in the course of our professional duties has been abused or neglected, or have reason to believe that a child seen in the course of our professional duties has been threatened with abuse or neglect, and that abuse or neglect of the child will occur, BSI must report this to the relevant county department, child welfare agency, police, or sheriff’s department.

• Adult and Domestic Abuse: If BSI believes that an elder person has been abused, or neglected, BSI may report such information to the relevant county department or state official of the long-term care ombudsman.

• Health Oversight: If the Wisconsin Department of Regulation and Licensing requests that BSI release records to them in order for the Psychology Examining Board to investigate a complaint, BSI must comply with such a request.

• 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 under state law and BSI will not release the 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. You will be informed in advance, if this is the case.

• Serious Threat to Health or Safety: If BSI has reason to believe, exercising professional care and skill, that you may cause harm to yourself or another, BSI must warn the third party and/or take steps to protect you, which may include instituting commitment proceedings.

• Worker’s Compensation: If you file a worker's compensation claim, BSI may be required to release records relevant to that claim to your employer or its insurer and may be required to testify.

• Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, BSI 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 seeing a BSI clinician.  Upon your request, BSI 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 my 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, a BSI 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.  BSI may deny your request. On your request,  a BSI 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, a BSI 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 BSI upon request, even if you have agreed to receive the notice electronically.

• BSI 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.
• BSI reserves the right to change the privacy policies and practices described in this notice. Unless BSI notifies you of such changes, however, BSI is required to abide by the terms currently in effect.
• If BSI revises policies and procedures, BSI will update this notice.

If you are concerned that BSI has violated your privacy rights, or you disagree with a decision BSI made about access to your records, you may contact BSI at 414-259-3900

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 went into effect on April 14th, 2003.