THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ AND REVIEW IT CAREFULLY.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. For psychologists this requires little change from the practice of confidentiality that has been required of our profession prior to HIPAA. In general, the HIPAA Act gives you, the client or patient, significant new rights to understand and control how your health care information is used. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. Please note that, for the practice of psychology, these HIPAA requirements compliment rather than add any significant change to our normal and usual practice as regards record keeping and confidentiality.
We may use and disclose your medical records only for each of the following purposes: treatment, payment and healthcare operations.
Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would be performing psychotherapy in this office, or making a referral to another health care provider for additional evaluation or treatment.
Payment means such activities as obtaining reimbursement services, confirming insurance coverage, billing or collection activities, and utilization review for managed care coverage and approval and/or at the request of a third party payer for your treatment (your insurance company). An example of this would be sending a bill for your psychotherapy visit to your insurance company, or telephonically, by mail, or by fax, sending the necessary clinical information for your insurance company to approve more sessions for coverage for you.
Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to any and all individually identifiable information.
We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that might be requested by or is of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your prior written authorization to take such actions.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer or to your psychotherapist.
The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction if Vermont law or Federal law indicates that to do so would be a violation of Duty to Warn Statutes of person or property, violation of mandated reporting of known abuse of a minor or child, or violation of mandated reporting of known abuse of an elderly or incapacitated person. As a psychotherapy client/patient you own the privilege of confidentiality, and no information, including your presence in therapy or the fact that you are a patient, will be disclosed without your specific written permission in a release of information request. Psychotherapy has traditionally always been more restricted in its mandated legal and ethical protection of your protected health information. HIPAA regulations do not affect any previous safeguards to your privacy as a patient, except in certain cases to strengthen them.
The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternate locations.
- The right to inspect and copy your protected health information.
- The right to amend your protected health information.
- The right to receive an accounting of disclosures of protected health information.
- The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected heath information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of July 2006 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, the Department of Health and Human Services, or the Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you in any fashion for filing a complaint.
Please speak with me or contact my office for more information. For more information about HIPAA or to file a complaint Please write to or contact:
The U.S. Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257 or Toll Free: 1-877-696-6775
DISCLOSURE INFORMATION
This information required by Vermont State law and is provided in compliance with that law and for your benefit and protection. As a client you are entitled to professional and ethical conduct and treatment at all times. Please read the following page. It includes information about professional conduct statutes, guidelines, and your entitlements as a client.
4.2 DISCLOSURE OF INFORMATION
Each licensed clinical social worker who provides psychotherapy services shall disclose to each client the following information, printed or typed in easily readable format:
- The licensed clinical social worker's professional qualifications and experience, including (A) all relevant graduate programs attended and all graduate degrees and certificates earned, including the full legal name of the granting institution, and (B) a brief description of any special qualifications and areas of practice.
- A copy of the statutory definition of unprofessional conduct (26 V.S.A. § 3210).
- Information on the process for filing a complaint with, or making a consumer inquiry to, the Director. Sample information cards are available from the Office.
Disclosure means, at a minimum, (A) posting the information and informing the client where the information is posted, or (B) having the information printed, displaying the printed information in an easily accessible location, and informing the client where the information is displayed, or (C) having the information printed and directly handing a copy of the information to the client. Not later than the third office visit, the licensed clinical social worker shall present to the client for signature a document stating that the information required to be disclosed in paragraphs (1), (2), and (3) above has been disclosed to the client. The clinical social worker shall also sign the document and shall retain the signed original. If, by the third office visit, disclosure cannot be made or the client declines to sign, the licensed clinical social worker shall prepare and sign a written statement explaining the omission, which shall be retained in place of the signed copy. A licensed clinical social worker who provides psychotherapy services to an institutionalized client shall not be required under this rule to repeat information already disclosed to the client pursuant to requirements of other governmental regulatory agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). However, in such cases, the licensed clinical social worker shall obtain from the client the signed document required in the paragraph immediately preceding, clearly indicating that the information required to be disclosed under this rule was disclosed to the client pursuant to the requirements of this rule or the requirements of another governmental regulatory agency. When the client is not able to understand the disclosure, as in the case of an institutionalized person, a minor, or an adult who is under the supervision of a guardian, the disclosure shall be made to a suitable parent or guardian. The Director may audit a licensed clinical social worker's records of information disclosure. Individuals to be audited may be selected at random.
My name is Katherine Zilboorg and I was licensed as an Independent Clinical Social Worker in the State of Vermont in May of 1986. I have maintained my license from that time until the present. A Clinical Social Work License must be renewed every two years, and requires 50 Hours of Professional Continuing Education Credits during each period for renewal. These hours must include a minimum of six (6) hours of continuing education in ethics. I received my MSW Graduate Degree from Adelphi University. I received 4000 hours (two years) of supervised work and training prior to licensure. I have been supervised and trained in both pre and post graduate settings in Individual, Family, and Group Therapy. I have also received both pre and post graduate training in Trauma Assessment and Treatment, Family and Marital Therapy, and Substance Abuse Evaluation and Treatment with individuals and families. I am a Licensed Alcohol and Drug Abuse Counselor, a have been certified as a Master Addictions Counselor by the National Association of Alcohol and Drug Abuse Counselors. I am also trained in Employee Assistance and Brief Therapy Models of treatment delivery and assessment. As a clinical social worker I work with and have experience in working with a wide variety of psychological and emotional problems, including Trauma, Complex PTSD, Depression, Anxiety, Substance Abuse and Dependence, and Dual Diagnosis issues with Substance Abuse Disorders and/or PTSD.
My Diplomas and certifications, and a copy of my Clinical Social Work License are all current, and displayed on the wall outside of my office.
Please feel free to ask me any questions at all about your treatment or my professional background, education, training, or experience.
Sincerely, Katherine Job. Zilboorg
The Vermont Statutes
Title 26: Professions and Occupations
CHAPTER 61. CLINICAL SOCIAL WORKERS
§ 3210. Unprofessional conduct
(a) The following conduct and the conduct set forth in section 129a of Title 3 by a licensed social worker constitute unprofessional conduct. When that conduct is by an applicant or a person who later becomes an applicant, it may constitute grounds for denial of a license:
- Failing to use a correct title in professional activity;
- conduct which evidences unfitness to practice clinical social work;
- Engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the licensee has had a professional relationship within the previous two years;
- Harassing, intimidating, or abusing a client or patient;
- Practicing outside or beyond a clinical social worker's area of training, experience or competence without appropriate supervision;
- Engaging in conflicts of interest that interfere with the exercise of the clinical social worker's professional discretion and impartial judgment;
- Failing to inform a client when a real or potential conflict of interest arises and to take reasonable steps to resolve the issue in a manner that makes the client's interest primary and protects the client's interest to the greatest extent possible;
- Taking unfair advantage of any professional relationship or exploiting others to further the clinical social worker's personal, religious, political or business interests;
- Engaging in dual or multiple relationships with a client or former client in which there is a risk of exploitation or potential harm to the client;
- Failing to take steps to protect a client and to set clear, appropriate and culturally sensitive boundaries, in instances where dual or multiple relationships are unavoidable;
- failing to clarify with all parties which individuals will be considered clients and the nature of the clinical social worker's professional obligations to the various individuals who are receiving services, when a clinical social worker provides services to two or more people who have a spousal, familial or other relationship with each other;
- Failing to clarify the clinical social worker's role with the parties involved and to take appropriate action to minimize any conflicts of interest, when the clinical social worker anticipates a conflict of interest among the individuals receiving services or anticipates having to perform in conflicting roles such as testifying in a child custody dispute or divorce proceedings involving clients.
(b) After hearing, and upon a finding of unprofessional conduct, an administrative hearing officer may take disciplinary action against a licensed clinical social worker or applicant. (Added 1985, No. 253 (Adj. Sess.), § 1; amended 1989, No. 250 (Adj. Sess.), § 4(b); 1993, No. 98, § 30; 1993, No. 222 (Adj. Sess.), § 6; 1997, No. 40, § 36; 1997, No. 145 (Adj. Sess.), § 52; 1999, No. 133 (Adj. Sess.), § 29.)
