HIPAA Protection of Privacy

April 2003
Welcome to the Counseling Center! This document ("the Agreement") contains
important information about the services offered to students and to others in the
Suffolk University community and outlines the policies and procedures that underlie
the delivery of those services. It also contains summary information about the Health
Insurance Portability and Accountability Act (HIPAA), a new federal law that took
effect on April 14, 2003. HIPAA provides new privacy protections and patient rights
with regard to the use and disclosure of "Protected Health Information" (PHI) used
for the purpose of treatment, payment for services, and health care operations.
The Counseling Center is open from 9:00-4:30, Monday through Friday. Limited
early morning and evening hours can also be scheduled, by appointment. When the
Center is closed, messages can be left through the University's voice-mail system.
After-hour messages are checked on a routine basis. Generally, calls are returned by
the following day at the latest, with the exception of weekends and holidays. If it is
difficult to be reached, clients should leave times they would like to be contacted by a
counselor. In emergency situations when it is difficult to wait for a return call from a
counselor, students should contact their family physician or the nearest emergency
room and ask for the psychologist and/or psychiatrist on call.
Short-term counseling, psychiatric evaluations and monthly medication follow-ups
are services provided free of charge to enrolled students at Suffolk University. In
cases where medication is recommended as part of ongoing treatment in the
Counseling Center, students bear the cost of payment for prescribed medications.
Clients are reminded by telephone of their scheduled appointment with the consulting
psychiatrists at least two days in advance of the appointment. It is important that
every effort be made to keep, and to be on time, for scheduled appointments. The
Counseling Center would appreciate notification of a cancellation as early as
possible, in order to offer appointments to clients on the waiting list. Clients should
also be aware that by not keeping follow-up appointments with the consulting
psychiatrist, it is very likely that prescribed medication(s) may run out and the wait to
have them re-filled will be longer than recommended by the prescribing psychiatrist.
State laws require that every student enrolled in a Massachusetts college or university
be covered by a health insurance policy that includes provisions for mental health
treatment. In the event that a counselor recommends an off-campus referral for
continued treatment, it is important for clients to evaluate what personal resources are
available to pay for mental health treatment and/or medication and to determine the
extent of mental health coverage provided by individual insurance policies. It is
sometimes difficult to determine exactly how much mental health coverage is
available. "Managed Health Care" plans often require authorization before they
provide reimbursement for mental health services. These plans are often limited to
short-term treatment approaches designed to work out specific problems that interfere
with a person's usual level of functioning. It may be necessary to seek approval for
more therapy after a certain number of sessions. If clients have questions about their
coverage, they should consult with their plan administrator. Counselors will assist
clients by helping to complete the required authorization forms, by providing
coverage information to new mental health professionals, and by acting as an
advocate to assure that clients receive the benefits to which they are entitled. It
should also be noted that some health insurance contracts may require that counselors
provide information relevant to the mental health services being recommended. In
such situations, counselors will make every effort to release only the minimum
personal information that is necessary for the purpose requested. Staff counselors will
also provide clients with copies of any submitted reports, if requested in writing.
Massachusetts laws on confidentiality protect the privacy of all communications
between a client and a psychologist. In the great majority of situations, licensed
psychologists will only release information about their treatment to others if clients
sign a written Aauthorization form that meets certain legal requirements imposed by
HIPAA. There are other situations that do not require such written authorizations. In
such cases, clients are generally notified that such contacts have taken place.
Examples of such interactions are listed below:
Psychologists may occasionally find it helpful to consult other health and
mental health professionals about a case. During such consultations, every
effort is made to avoid revealing the identity of clients. The consultant is
other professionals are also legally bound to keep the information
confidential. Unless clients raise objections to such interactions, counselors
generally do not provide notification of such consultations unless they feel
that it is important for the work being undertaken with their clients. In such
situations, each consultation is recorded in clients' Clinical Records (which is
called "PHI" in the Notice of Psychologist's Policies and Practices to Protect
the Privacy of Health Information).
The Counseling Center employs administrative staff to assist psychologists in
providing services to students. In a very limited number of cases, that
protected information may be shared between staff members for both clinical
and administrative purposes, such as scheduling, case management and to
maintain quality assurance. Members of the Counseling Center staff are
bound by the same rules of confidentiality and have received training about
protecting your privacy and have agreed not to release any information
outside of the practice without the permission of a professional staff member.
In order to assure that it continues to meet accepted standards of care, the Counseling Center has form
relationships with the International Association of Counseling Services (IACS) and the American
Psychological Association (APA). As required by HIPAA, the Counseling Center will establish a form
business associate contract with its accrediting organizations, in which they will agree to maintain the
confidentiality of your personal health information except as specifically allowed in the contract or
otherwise required by law.
There are some situations where counselors are permitted or required to disclose
information without the consent or authorization by clients:
If clients are involved in a court proceeding and a request is made for
information concerning either diagnosis and/or the progress of treatment, such
information is protected by the laws governing the use and release of
privileged communications. Counselors cannot provide any information
without their client's (or a designated legal representative's) written
authorization, or a court order. If clients are either involved in or
contemplating litigation, they should consult with their attorney to determine
whether a court would be likely to order their counselor to disclose otherwise
protected information.
• If a government agency is requesting the information for health oversight
activities, counselors may be required to provide it for them.
• If a client files a complaint or lawsuit against a counselor, that counselor may
disclose relevant client information as part of h/her defense against the
• If a client files a worker's compensation claim, counselors must, upon written
request, provide appropriate information, including a copy of the client's
record, to the client's employer, the insurer or the Department of Workmen's
There are some situations in which mental health professionals are obligated to take
actions that they believe are necessary to attempt to protect others from harm. To do
so, they may have to reveal some information about a client's treatment. Such cases
have been extremely rare in the Counseling Center.
If a counselor has reasonable cause to believe that a child under age 18 is
suffering physical or emotional injury resulting from abuse inflicted upon him
or her which causes harm or substantial risk of harm to the child's health or
welfare (including sexual abuse), or from neglect (including malnutrition), the
law requires that h/she must file a report the appropriate governmental
agency, usually with the Department of Social Services. Once such a report is
filed, counselors may be required to provide additional information.
If a counselor has reason to believe an elderly or handicapped individual is
suffering from abuse, the law requires that h/she must file a report with the
appropriate governmental agency Department of Elder Affairs. Once such a
report is filed, the counselor may be required to provide additional
If a client communicates an immediate threat of serious physical harm to an
identifiable victim or if a client has a history of violence and the apparent
intent and ability to carry out the threat, a counselor may be required to take
protective actions. These actions may include notifying the potential victim,
contacting the police, and/or seeking hospitalization for the client.
If a client threatens to harm himself/herself, counselors may be obligated to
seek hospitalization for him/her, or to contact family members or others who
can help provide protection.
If such a situation arises, counselors make every effort to fully discuss the
requirements with clients before taking any action and will limit any disclosures to
what is necessary and required by law.
While this written summary of exceptions to confidentiality is written to provide
helpful information about potential problems, it is important that clients discuss any
questions or concerns that they may have now or in the future with their counselor. In
situations where specific advice is required, formal legal advice may also be needed.
If clients are under 18 years of age and are not legally emancipated, they should be
aware that the law allows parents to examine their child's treatment records, unless
the counselor believes that such a review would be harmful to the client and to
his/her treatment. Because privacy in psychotherapy is often crucial to successful
progress, particularly with teenagers, the Counseling Center may request an
agreement from parents that they consent to give up their access to their child's
records. If clients are under-age and their parents agree, counselors may provide them
only with general information about the progress of the treatment and client's
attendance at scheduled sessions. Counselors may also provide parents and/or legal
guardians with a summary of treatment when it is complete. Any other
communication will require client's written authorization, unless counselors
determine that clients may be in danger or could be a danger to someone else. In such
cases, counselors may then notify parents and/or legal guardians, as needed and
required by law. Before providing any information to parents or guardians,
counselors discuss the need to do so with clients and, if possible under the
circumstances, to respond to any objections raised by their clients.
Massachusetts state laws and standards for the practice of psychology require that
Protected Health Information be included in Clinical Records. Among other things,
such records include information regarding client's reasons for seeking therapy, a
description of the ways in which personal problems impacts clients' lives, diagnosis
(if there is one), treatment goals and progress toward those goals, clients' social and
medical history, previous treatment history, any past treatment records received from
other providers, reports of any professional consultations, and any records that may
have been sent to insurance carriers authorizing referrals and/or treatment. Clinical
records will also include the contents of conversations between clients and
counselors, assessments of those conversations, and how they may impact on
treatment. Clients may examine and/or receive a copy of their Clinical Record, if
requested in writing, unless the counselor believes that such access might be harmful
to the client. In those situations, clients have a right to a summary and to have the
record sent to another mental health provider or to a designated legal representative.
Due to their content, clinical records can be misinterpreted and/or be upsetting to
untrained readers. Accordingly, it is recommended that clients initially review them
in the presence of their counselor. There will beThe exceptions to this policy are
contained in the attached Notice Form.
While insurance companies can request a copy of Clinical Records, they cannot
receive a copy without a client's written authorization. Insurance companies cannot
require a client's authorization as a condition of coverage nor penalize clients in any
way for their refusal to sign such authorizations.
HIPAA provides clients with several new or expanded rights with regard to their
Clinical RecordsClinical Record and the protection of private health information.
These rights include requesting amendments to client-records; requesting restrictions
on the amount of information from Clinical records; Clinical Records that can be
disclosed to others; requesting an accounting of most disclosures of protected health
information that clients have neither consented to nor authorized; determining the
location to which protected information disclosures are sent; having any complaints
made about the Counseling Center's policies and procedures recorded in client
records; and the right to a paper copy of this Agreement, and the Counseling Center's
privacy policies and procedures. Counselors will be pleased to discuss any of these
rights with clients, as needed and requested.
Psychologists are required by law to maintain the privacy of PHI and to
provide clients with a notice of their legal duties and privacy practices with
regard to PHI.
Psychologists may reserve the right to change the privacy policies and
practices described in this notice. Unless they notify clients of such changes,
however, counselors are required to abide by the terms currently in effect.
If counselors revise their policies and/or procedures, they must provide clients
with a revised notice, by mail or by an alternative form of notification, as per
client's written request.
If clients are concerned that their privacy rights may have been violated, or disagree
with a decision that has been made about access to personal records, they may
Dr. Wilma Busse, Ed.D
Director/Privacy Officer, Suffolk University Counseling Center
@ 617-573-8226
Clients may also send a written complaint to the Secretary of the U.S. Department of
Health and Human Services. The person listed above will provide the appropriate
address upon request.
Rev. 4/01/11