Forms

PLEASE NOTE: For Authorization to Disclose Forms - a PHYSICAL signature of your FULL LEGAL name (first & last) is required.

You must print the form, physically sign with a pen, take a picture/scan it, and then upload.
Digital signatures (for example, simply typing in your name) are NOT valid.
Failure to follow these important instructions may cause delays with your request.
For records requests, there may be a fee depending on the nature of the request.

For more information on Releases of Information, please refer below.

Notice of Privacy Practices

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.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent.

As a reminder, your consent provides:

The right for Penn State CAPS staff to seek supervision and/or professional consultation, within CAPS, to aid us in our work with you.
The acknowledgment that your records may be shared with Penn State counseling services at participating commonwealth campuses via a shared EMR on a clinical need-to-know basis.
The understanding that CAPS records may be shared with Penn State University Health Services via a shared EMR on a clinical need-to-know basis.

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”

- Treatment is when the Center for Counseling and Psychological Services (CAPS) provides, coordinates or manages your mental health care and other services related to your mental health. In addition to therapy and psychiatric services, an example of treatment would be when we consult with another CAPS provider.

-We includes the professional staff at CAPS, including psychologists, psychiatric providers, social workers, counselors, graduate trainees, and administrative staff assistants.

- Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose PHI to Pennsylvania State Aetna Student Health Insurance to obtain reimbursement for your health care or to determine eligibility or coverage.

- Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

“Use” applies only to activities within our center such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of our center, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

We 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 we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes we may make about our conversation with a client during a private, group, joint, or family counseling session, which we keep 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) We have 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.

III. Uses and Disclosures with Neither Consent nor Authorization

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

Child Abuse Reporting: (effective 1/1/2015) – CAPS may be required by Pennsylvania law (Act 31, 2014) to report the following types of child abuse (depending on the nature and date of abuse) to PA Child Protective Services if we have reasonable cause to suspect that a child (a person who is currently less than 18 years of age) has been the victim of child abuse:
- If you are less than 18 years of age and disclose that you are the victim of child abuse.
- If you disclose that an identifiable child has been the victim of child abuse. A report may be required even if we do not meet with the child.
- If you disclose that you abused a child when you were 14 years of age or older. A report may be required even if the victim is no longer in danger.
Adult and Domestic Abuse: If we have reasonable cause to believe that an older adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we may report such to the local agency which provides protective services.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services we provided you or the records thereof, such information is privileged under state law, and we will not release the information without your written consent, 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 Self: If you express a serious threat or intent to kill or seriously injure yourself, and we determine that you are likely to carry out the threat, we must take reasonable measures to prevent harm. Reasonable measures may include notifying the individual(s) or authorities who are in a position to help prevent harm.
Serious Threat to Others: If you express a serious threat or intent to kill or seriously injure an identified (or readily identifiable person) or group of people, and we determine that you are likely to carry out the threat, we must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of the threat or intent.
Worker’s Compensation: If you file a worker’s compensation claim, we will be required to file periodic reports with your employer which shall include, where pertinent, history, diagnosis, treatment, and prognosis.

There may be additional disclosures of PHI that we are required or permitted by law to make without your consent or authorization; however, the disclosures listed above are the most common.

IV. Client’s Rights and Mental Health Provider’s Duties

Client’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, we are 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 us. Upon your request, we will send correspondence to an address you specify.
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial 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. We may deny your request. On your request, we 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, we 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 us upon request, even if you have agreed to receive the notice electronically.

Mental Health Providers’ Duties:

We are 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.
We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
This notice form will be updated if we revise our policies and procedures. You will be notified by your current provider if this occurs.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns about your privacy rights, you may contact the Associate Director of Clinical Services of CAPS, ccaps@psu.edu, 814-863-0395.

If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint the Associate Director of Clinical Services at CAPS, ccaps@psu.edu, 814-863-0395.

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.

You have specific rights under the Privacy Rule. We will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on November 27, 2012.

We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice by having a paper copy available to you the next time you come to the office.

Search

Download Forms