Notice of Privacy Practices
This notice describes how health information about you may be used and disclosed and how you can get access to this health information. Please review it carefully.
In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. However, there are several exceptions, which are specified below.
I may use or disclose your health information without your written consent in the following cases:
For treatment…
We may use your health information to provide you with treatment or services. For example, a provider may use the information in your medical record to determine which treatment option best addresses your health needs.
For payment…
In order for an insurance company to pay for your treatment, a claim must be submitted that identifies you, your diagnosis, and the treatment provided to you.
For health care operations…
Dr. Loomis may need your diagnosis, treatment and outcome information in order to improve the quality or cost of care delivered.
Health oversight…
If the Wisconsin Department of Regulation and Licensing requests that I release records to them in order for the Psychology Examining Board to investigate a complaint, I must comply with such a request.
Child or elder abuse…
If I have reasonable cause to suspect that a child seen in the course of my professional duties has been abused or neglected, or have reason to believe that a child has been threatened with abuse or neglect, and that abuse or neglect of the child will occur, I must report this to the relevant county department, child welfare agency, police, or sheriff’s department.
If I believe that an elder person has been abused or neglected, I may report such information to the relevant county department or state official.
Judicial proceedings…
I must release your information if a judge orders me to testify.
Serious threat to health or safety…
If I have a concern that you may be of imminent danger to yourself or others, I will take whatever steps I deem necessary to protect you or others from harm.
Case consultation…
I consult with colleagues who have expertise in relevant areas in order to provide the best services possible. I do not mention names or identifying information to the professionals I consult with.
Worker’s compensation…
If you file a worker’s compensation claim, I may be required to release records relevant to that claim to your employer or its insurer and may be required to testify in administrative and/or court hearings.
There may be additional disclosures of protected health information that I am required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common.
Uses and disclosures requiring authorization:
I may use or disclose protected health information for purposes outside of treatment and payment (and the other situations described above) when your appropriate informed consent or authorization is obtained. In those instances, I will obtain an authorization from you before releasing this information.
You may revoke an authorization at any time, provided each revocation is in writing. However, you cannot retroactively revoke a release of information for information that has already been exchanged. Also, if you revoke authorization for me to provide information to your health insurance company or another third-party payer and they refuse to pay, you would be responsible for the fees.
Your health information rights:
You have a right to take the following actions listed below.
Inspect and copy your health information…
You have the right to inspect and obtain a copy of your health information. In some cases, I may require that we review the information together. Upon your request, I will discuss with you the details of the request process.
Request to correct your health information…
If you believe your health information is incorrect, you may ask to have the information corrected. However, if I did not create the health information that you believe is incorrect, or if I disagree with you and believe your health information is correct, I may deny your request. Upon your request, I will discuss with you the details of the request process.
Request restrictions on certain uses and disclosures…
You have the right to ask for restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree in all circumstances to your requested restriction.
Right to receive confidential communications by alternative means and at alternative locations…
You have the right to request in writing and receive confidential communications by alternative means and at alternative locations. For example, you may not want a family member to know that you are seeing me. Upon your written request, I will send your bills to another address.
Right to an accounting…
You generally have the right to receive an accounting of disclosures regarding you. On your request, I will discuss with you the details of the accounting process.
Right to a paper copy of this notice…
You are being provided with a copy of this notice. Upon your request, you may at any time receive another copy of this notice.
Right to complain…
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me. If you believe that your privacy rights have been violated, you may file a written complaint either with me (Restorative Sleep, LLC, 201 N. Mayfair Rd., Milwaukee, WI, 53226) and/or with the Secretary of the Department of Health and Human Services (I can provide you with a specific address upon request). You have specific rights under the HIPPA Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
Right to restrict disclosures…
You have the right to restrict disclosure of information to a health plan. However, if you restrict disclosure of information requested by your health plan, they may not pay for the services, and then payment would be your responsibility.
Right to be notified if there is a breach of your unsecured Protected Health Information (PHI)…
You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) the PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.
If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact Dr. Loomis at (414) 698-2654.
My duties related to this notice:
I am required by law to maintain the privacy of your information and to provide you with a notice of my legal duties and privacy practices with respect to protected health information. This notice will go into effect on 1/13/09 and has been revised on 1/1/18. I reserve the right to change the terms of privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you with copies made available in my office.