ALBUQUERQUE PSYCHOLOGY GROUP (APG)
Notice of Psychologists’ Policies and Practices to Protect the Privacy of
Your Health Information
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
Your psychologist may use or disclose your protected health information (PHI), for
treatment, payment, and health care operations purposes, with your consent. To clarify
this, below are some definitions.
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Protected Health Information (PHI) refers to information in your health care
record that could identify you.
Treatment is when your psychologist provides, coordinates or manages your
psychological care. An example of this could be when your psychologist consults
with another health care provider in order to improve your care.
Payment is when your provider releases PHI to you in the form of a statement of
fees and psychiatric diagnoses for which you have been seen by your APG
psychologist. You can use such a statement to obtain out-of-network
reimbursement for your payments to your APG psychologist, if your insurance
policy allows this. Albuquerque Psychology Group does not accept insurance
payments directly and so will not directly release any PHI to any insurance entity.
Health care operations are activities that relate to the performance and operation
of our practice. Examples of these are administrative, performance improvement,
and accounting activities.
“Use” applies only to activities within Albuquerque Psychology Group, such as
consultation between psychologists or performing audits.
“Disclosure” applies to activities outside Albuquerque Psychology Group, such as
releasing information about you to another health care provider or other parties.
II. Uses and Disclosures Requiring Authorization
Your psychologist may use or disclose PHI for purposes outside of treatment, payment,
and health care operations when your appropriate authorization is obtained. An
“authorization” is a written permission above and beyond the general consent you grant
by signing this document. Such a document permits only specific disclosure, and must be
obtained from you by your psychologist in those instances in which your psychologist is
asked for information for purposes outside of treatment, payment and health care
operations. Your psychologist will also need to obtain an authorization before releasing
your psychotherapy notes to any outside party. “Psychotherapy notes” are notes your
psychologist has made documenting your psychotherapy sessions. These notes are given
a greater degree of privacy protection than other PHI.
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You may revoke all such authorizations at any time, provided the revocation is in writing.
III. Uses and Disclosures with Neither Consent nor Authorization
Your provider may use or disclose PHI without your consent or authorization in the
following circumstances:
 Child Abuse. If your psychologist has reasonable cause to believe than a child is
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being abused, neglected, or exploited, your psychologist is required to report this
to appropriate agencies.
Elder Abuse. If your psychologist has reasonable cause to believe that an
incapacitated adult is being abused, neglected, or exploited, he/she must report
this to appropriate agencies.
Health Oversight. If the New Mexico Board of Psychologist Examiners is
conducting an investigation, your provider is required to disclose your mental
health records upon receipt of a subpoena from the Board.
Judicial or 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 your psychologist may not release information without written authorization
from you or your personal or legally-appointed representative, or court order. If
you are seeing an APG psychologist for a court-ordered evaluation, or are being
evaluated for a third party (for example, for employment), the privilege does not
apply. You would be informed in advance if this were the case.
Serious Threat to Health or Safety. If your psychologist were to judge that
disclosure of your private information is necessary to protect against a substantial
and imminent risk that you will seriously harm yourself or another person, your
psychologist has a duty to report this information to the appropriate people (for
example, the police or a potential victim).
Worker’s Compensation. When a claim is filed, your provider is required by law
to release those records that are directly related to any injuries or disabilities
claimed by you (for which you are receiving benefits from your employer) to you,
your employer, your employer’s insurer, a peer review organization, or the health
care selction board.
IV. Patient’s Rights and Psychologist’s Duties
Patient’s Rights:
 Right to Request Restrictions—You have the right to request restrictions on
certain uses and disclosures of PHI. However, your psychologist has the right to
retain the ability to make the disclosures required by law, as outlined in section III
above.
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 Right to Receive Confidential Communications by Alternative Means and at
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Alternative Locations—You have the right to request and receive confidential
communication of PHI by alternative means. (For example, you may not want a
family member to know you are seeing a psychologist. Upon your request, your
psychologist will send correspondence to another address, or will refrain from
telephone communication on your home phone.)
Right to Inspect and Copy—You have the right to inspect and/or obtain a copy of
your PHI as long as your psychologist maintains the record (typically 7 years).
Right to Amend—you have the right to request an amendment of PHI for as long as
your psychologist maintains the record. Your provider may deny this request.
Right to an Accounting—You generally have the right to receive an accounting of
disclosures of PHI for which you have neither provided consent nor authorization
(as described in Section III of the Notice).
Right to a Paper Copy—You have the right to obtain a paper copy of this Notice,
upon your request.
Right to be notified if there is a serious breach of your usecured PHI.
Right to request a copy of your PHI.
Psychologist’s Duties:
 Your psychologist is required by law to maintain the privacy of PHI and to provide
you with a notice of legal duties and privacy practices with respect to PHI.
 Your psychologist reserves the right to change the privacy policies and practices
described in this notice. Unless your psychologist notifies you of such changes,
however, he/she is required to abide by the terms in this Notice.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision your provider makes
about access to your records, or have other concerns about your privacy rights, you may
contact your provider at (505) 225-1154.
If you believe your privacy rights have been violated and wish to file a complaint you may
send an email complaint to APG at ABQpsychology@gmail.com . You may also send a
written complaint to the Secretary of the US Department of Health and Human Services.
You have special rights under the Privacy Rule, and your psychologist will not retaliate
against you for exercising your right to file a complaint.
VI. Effective Date
This Notice goes into effect July 1, 2014.
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VII. Signature
By signing below, I acknowledge that I have read and understood this Notice and give
consent for uses of my PHI that do not require authorization, as outlined in Section I of
this document.
Name (please print): _____________________________________________________________________________
Signature: _________________________________________________________________________________________
Date: _______________________________________________________________________________________________
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