Notice of Michael Lax’s Policies and Practices to Protect the Privacy of Your Health Information

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

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

Michael Lax (and his professional and administrative staff) 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”
  • Treatment is when Michael Lax provides, coordinates, or manages your health care and other services related to your health
    care. An example of treatment would be when a Michael Lax consults with another health care provider, such as your family
    physician or another psychologist.
  • Payment is when Michael Lax obtains reimbursement for your healthcare. Examples of payment are when Michael Lax
    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 Michael Lax’s professional 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 practice such as sharing, employing, applying, utilizing, examining, and
  analyzing information that identifies you.
• “Disclosure” applies to activities outside of our practice, such as releasing, transferring, or providing access to information
  about you to other parties

2. Uses and Disclosures Requiring Authorization

Michael Lax 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. In those instances when Michael Lax is asked for information for purposes outside of
treatment, payment or health care operations, Michael Lax will obtain an authorization from you before releasing this
information. Michael Lax will also obtain an authorization from you before using or disclosing PHI in a way that is not
described in this Notice.

You may revoke all such authorizations of PHI at any time, provided each revocation is in writing. You may not revoke an
authorization to the extent that (1) Michael Lax has already relied on that authorization; or (2) if the authorization was
obtained as a condition of obtaining insurance coverage, the law provides the insurer the right to contest the claim under the
policy.

III. Uses and Disclosures with Neither Consent nor Authorization
Michael Lax may use or disclose PHI without your consent or authorization in the following circumstances:
•Child Abuse – If, in the ordinary course of our work Michael Lax, has reasonable cause to suspect or believe that any child
under the age of eighteen years (1) has been abused or neglected, (2) has had a non-accidental physical injury or injury which
is at variance with the history given of such injury, inflicted upon such child, or (3) is placed at imminent risk of serious
harm, then Michael Lax must report this suspicion or belief to the appropriate authority.
•Adult and Domestic Abuse – If Michael Lax knows or in good faith suspects that an elderly individual or an individual, who
is disabled or incompetent, has been abused, Michael Lax may disclose the appropriate information as permitted by law.
•Health Oversight Activities – If a State of Connecticut licensing board or the Department of Public Health is investigating
Michael Lax, the board may subpoena records relevant to such investigation.
•Judicial and 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 Michael Lax
will not release information without the written authorization of you or your legally appointed representative or court order.
The privilege does not apply when you are being evaluated for a third party or where the evaluation or release of information
is court ordered.
•Serious Threat to Health or Safety – If Michael Lax believes in good faith that there is risk of imminent personal injury to
you or to other individuals or risk of imminent injury to the property of other individuals, Michael Lax may disclose the
appropriate information as permitted by law.
•Worker’s Compensation – Michael Lax may disclose protected health information regarding you 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.
•Other – When the use and disclosure without your consent or authorization is allowed under other sections of Section
164.512 of the Privacy Rule and the state’s confidentiality law. This includes certain narrowly-defined disclosures to law
enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical
examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions
such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
IV. Patient’s Rights and Michael Lax’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. However, Michael Lax 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 a patient or client of the office. On your request, Michael Lax 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 our mental health and billing
records used to make decisions about you for as long as the PHI is maintained in the record. Michael Lax may deny your
access to PHI under certain circumstances, but in some cases,  you may have this decision reviewed. On your request,
Michael Lax 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.
Michael Lax may deny your request. On your request, Michael Lax 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. On your request,
Michael Lax 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 upon request, even if you have agreed to
receive the notice electronically.
•Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket – You have the right to restrict certain
disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.
•Right to Be Notified if There is a Breach of Your Unsecured 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) that 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.
Michael Lax’s Duties:
•Michael Lax is required by law to maintain the privacy of PHI and to provide you with a notice of its legal duties and
privacy practices with respect to PHI.
•Michael Lax reserves the right to change the privacy policies and practices described in this notice. Unless Michael Lax
notifies you of such changes, however, Michael Lax is required to abide by the terms currently in effect.
•If Michael Lax revises his policies and procedures (for which he reserves the right to do), Michael Lax will provide you
with a revised notice by directly handing it to you if you are actively seen in his office at that time.
V. Complaints
If you are concerned that Michael Lax may have violated your privacy rights, or you disagree with a decision Michael Lax
made about access to your records, you may contact him to discuss this matter further. You may also send a written
complaint to the Secretary of the U.S. Department of Health and Human Services.
VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice went into effect on January 1, 2017.