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.  HIPAA requires you are provided with a Notice of Privacy Practices for use and disclosure of Protected Health Information (PHI) for treatment, payment and health care operations.  The law requires your signature is obtained, acknowledging we provided you with this information.  When you sign this document, you will be acknowledging that you have received this information. Please read these forms carefully and discuss any questions you have with your clinician.

  • Uses and Disclosures for Treatment, Payment, and Health Care Operations

Your healthcare provider 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 about your health record that could identify you.
  • Treatment is when your healthcare provider, coordinates, provides or manages your mental health care or other services related to your healthcare. 
  • Payment is reimbursement for your healthcare.  Examples of payments are when your healthcare provider discloses your PHI to your health insurer 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 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 the office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  • “Disclosure” applies to activities outside of the office, such as releasing, transferring, or providing access to information about you to other parties.
  • Uses and Disclosures Requiring Authorization

Your healthcare provider may use or disclose PHI for purposes outside of treatment, payment, or 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.    Your healthcare provider will also need to obtain an authorization before releasing Psychotherapy Notes if those notes are created as part of your treatment. 

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) your healthcare provider has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

  • Uses and Disclosures with Neither Consent nor Authorization

Your healthcare provider may use or disclose PHI without your consent or authorization in the following circumstances:

  • Child Abuse – If your healthcare provider has reason to suspect that a child has been injured as a result of physical, sexual, or emotional abuse or neglect, your healthcare provider must report the matter to the appropriate authorities as required by law.
  • Adult and Domestic Abuse – If your healthcare provider has reasonable cause to believe that an adult is being or has been abused, neglected or exploited or is in need of protective services, your healthcare provider must report this belief to the appropriate authorities as required by law.
  • Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about the professional services your clinician provides you and/or the records thereof, such information is privileged under state law, and your healthcare provider will not release information without the written authorization of you or your legally appointed representative or a court order.  The privilege may 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 to Others – If your healthcare provider believes that there is a substantial likelihood that you have threatened an identifiable person and that you are likely to act on that threat in the foreseeable future, your healthcare provider may disclose information in order to protect that individual.
  • Serious Threat to Health or Safety to Self – If your healthcare provider believes that there is a substantial likelihood that you may harm yourself; healthcare information may need to be disclosed to others. 
  • Worker’s Compensation – Your healthcare provider may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

In the event that you file a lawsuit against Kansas City Psychiatry, LLC or your clinician, relevant medical records may need to be accessible by the court


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

  • Patient’s Rights and Clinician Duties

Patient’s Rights:

  • Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information.  However, your healthcare provider is not required to agree to a restriction you request.
  • Right to Receive Confidential Communication 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 your healthcare provider.  On your request, your healthcare provider 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 your mental health and billing records for as long as the PHI is maintained in the record.  Your healthcare provider may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  On your request, your healthcare provider may 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.  Your healthcare provider may deny your request. 
  • Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. 
  • Right to a Paper Copy – You have the right to obtain a paper copy of the notice from your healthcare provider upon request, even if you have agreed to receive the notice electronically.
  • Questions and Complaints

If you have questions about this notice, disagree with a decision your healthcare provider makes about access to your records, or have other concerns about your privacy rights, you may contact your healthcare provider.  If you believe that your privacy rights have been violated and wish to file a complaint with your healthcare provider, you may file a written complaint.

  • Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on 09/01/2009.  Your healthcare provider  reserves the right to change the terms of this notice and to make the new notice provisions effective for PHI that are maintained.

About Telepsychiatry Associates!

TelePsychiatry Associates, LLC practitioners are skilled in the practice of treating a wide variety of different conditions in a compassionate manner including: depression, bipolar affective disorder, substance dependency, opiate dependency including Suboxone treatment, anxiety disorders, post-traumatic stress disorder, trauma related to sexual or physical abuse, and weight loss management, among others.

The types of treatments provided will depend upon your practitioner and the problems needing attention. The first one to two sessions will involve critical listening in order to obtain a comprehensive understanding of the issues at hand. Treatments that follow could include the discriminating use of medication, empathic psychotherapy, or some combination of both. If appropriate, additional therapeutic treatments may be employed including other psychotherapists, group therapies, structured activities, assigned readings, etc.

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