Summit Psychological Associates, Inc. Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. 

Please review it carefully.

Our Duty to Safeguard Your Protected Health Information: Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for health care is considered “Protected Health Information” (PHI).  We are required to extend certain protections to your PHI, and to give you this notice about our privacy practices that explains how, when and why we may use or disclose your PHI.  Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the intended purpose of the use of disclosure.

We are required to follow the privacy practices described in this notice though we reserve the right to change our privacy practices and the terms of this notice at any time.

You Have the Right to Receive this Notice: You have a right to receive a paper copy of this Notice.  You may request a copy of the new notice from any of SPA’s offices or view it on our website.

How We May Use and Disclose Your Protected Health Information: We use and disclose Personal Health Information for a variety of reasons.  We have a limited right to use and/or disclose your PHI for purposes of treatment, payment and for our health care operations.  For uses beyond that, we must have your written authorization unless the law permits or requires us to make the use or disclosure without your authorization.  If we disclose your PHI to an outside entity in order for that entity to perform a function on our behalf, we must have in place an agreement from the outside entity that it will extend the same degree of privacy protection to your information that we must apply to your PHI.  However, the law provides we are permitted to make some uses/disclosures without your consent or authorization.  The following describes and offers examples of our potential uses/disclosures of your PHI.

Uses and Disclosures Relating to Treatment, Payment, or Heath Care Operations: Generally, we may use or disclose your PHI as follows:

  • For Treatment:  We may disclose your PHI to doctors, nurses, and other health care personnel who are involved in providing your health care.
  • To Obtain Payment: We may use/disclose your PHI in order to bill and collect payment for your health care services. For example, we may contact your private insurer to get paid for services that we delivered to you.
  • For Health Care Operations:  We may disclose your PHI to designated staff in our other offices or programs. For example, we may use your PHI in evaluating the quality of services provided by your therapist.
  • Appointment Reminders:  Unless you provide us with alternative instructions, we will call and leave appointment reminders for you at home.

Uses and Disclosures of PHI Requiring Authorization: For uses and disclosures beyond treatment, payment and health care operations purposes we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below.  Authorizations can be revoked, in writing, at any time to stop future uses/disclosures except to the extent that we already undertaken an action in reliance upon your authorization.

Uses and Disclosures of PHI from Mental Health Records Not Requiring Consent or Authorization: The law provides that we may use/disclose your PHI from mental health records without consent or authorization in the following circumstances:

  • When required by law:  We may disclose PHI when a law requires that we report information about suspected abuse, neglect or relating to suspected to criminal activity, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.
  • For health oversight activities:  We may disclose PHI to a protection and advocacy agency, or another agency responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents, and monitoring of the Medicaid program.
  • Relating to descendants:  We may disclose PHI related to a death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.
  • To avert threat to health or safety:  In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.
  • For research purposes:  In certain circumstances and under supervision of a privacy board, we may disclose PHI to our Utilization Management or Peer Review Committees or their designees in order to assist mental health research.
  • For specific government functions:  We may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government benefit programs relating to eligibility and enrollment and for national security reasons, such as protection of the President.


Your Rights Regarding Your Protected Health Information: You have the following rights relating to your protected health information:

  • To request restrictions on uses/disclosures:  You have the right to ask that we limit how we use or disclose your PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.
  • To choose how we contact you:  You have the right to ask that we send you information at an alternative address or by an alternative means. We must agree to your request as long as it is reasonably easy for us to do so.
  • To inspect and request a copy of your PHI:  You have a right to see your Protected Health Information upon your written request.  We will respond to your request within 30 days. If you want copies of your PHI, a charge for copying may be imposed, depending on your circumstances. You have a right to choose what portions of your information you want copied and to have prior information of the cost of copying.
  • To request amendment of your PHI:  If you believe that there is a mistake or missing information in our record  of your PHI, you may request, in writing, that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is: (1) correct and complete (2) not created by us and/or not part of our records, or (3) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the change in the PHI.
  • To find out what disclosures have been made:  You have a right to get a list of when, to whom, for what purpose, and what content of your PHI has been released except on instances of disclosure for treatment, payment, and health care operations. The list also will not include any disclosures made to law enforcement officials or disclosures made before April 14, 2003. We will respond to your written request for such a list within 60 days of receiving it. Your request can relate to disclosures going as far back as six years from the effective date. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.


How to Submit a Complaint about our Privacy Practices

If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed below. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington D.C., 20201 or call 1-877-696-6775.  We will take no retaliatory action against you if you make such complaints.

Contact Person for Information or to Submit a Complaint

If you have questions about this Notice or any complaints about our privacy practices, please contact our Privacy Officer at:

37 North Broadway Street

Akron, OH 44308

Telephone:  (330) 535-8181