3421 E State Boulevard, Fort Wayne, Indiana 46805 (260) 482-8427

Notice of Privacy and Nondiscrimination Practices

This notice is a summary of the Indiana notice form and describes how psychological and mental health information about you may be used and disclosed and how you can get access to this information. The entire notice is available upon request.

The following defines procedures applying to all clinical and administrative staff at psychological service associates, Inc.

I.  Uses & disclosures for Treatment, Payment, & Health Care Operations

This office may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written authorization. To help clarify these terms, here are some definitions:

    • Treatment is when we provide, coordinate, or manage your health care and other services related to your health.
    • Payment is when we obtain reimbursement for your healthcare.
    • Health Care Operations are activities that relate to the performance and operation of our practice.

II.  Other Uses and Disclosures Requiring Authorization

This office may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained.  We also will need to obtain a specific authorization before releasing your Psychotherapy Notes if such notes are maintained.  Psychotherapy notes are given a greater degree of protection than PHI.
You may revoke all such authorization (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing.

III.  Uses and Disclosures with Neither Consent nor Authorization

This office may use or disclose PHI without your consent or authorization in the following circumstances:

IV. Patient’s Rights and Provider’s Duties

Patient’s Rights:

Provider’s Duties:

V.  Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision made about access to your records, you may contact our office.  You also may 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 April 14, 2003.

Notice of Nondiscrimination Practices

Psychological Service Associates, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Psychological Service Associates, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

Psychological Service Associates, Inc. erfüllt geltenden bundesstaatliche Menschenrechtsgesetze und lehnt jegliche Diskriminierung aufgrund von Rasse, Hautfarbe, Herkunft, Alter, Behinderung oder Geschlecht ab.

Psychological Service Associates, Inc. respecte les lois fédérales en vigueur relatives aux droits civiques et ne pratique aucune discrimination basée sur la race, la couleur de peau, l'origine nationale, l'âge, le sexe ou un handicap.

Psychological Service Associates, Inc. voldoet aan de geldende wettelijke bepalingen over burgerrechten en discrimineert niet op basis van ras, huidskleur, afkomst, leeftijd, handicap of geslacht.

Psychological Service Associates, Inc. 遵守適用的聯邦民權法律規定,不因種族、膚色、民族血統、年齡、殘障 或性別而歧視任何人。

Psychological Service Associates, Inc. postępuje zgodnie z obowiązującymi federalnymi prawami obywatelskimi i nie dopuszcza się dyskryminacji ze względu na rasę, kolor skóry, pochodzenie, wiek, niepełnosprawność bądź płeć.

Psychological Service Associates, Inc. pridržava se važećih saveznih zakona o građanskim pravima i ne pravi diskriminaciju po osnovu rase, boje kože, nacionalnog porijekla, godina starosti, invaliditeta ili pola.

Psychological Service Associates, Inc. は適用される連邦公民権法を遵守し、人種、肌の色、出身国、 年齢、障害または性別に基づく差別をいたしません。

Psychological Service Associates, Inc. ua raws cov kev cailij choj yuam siv ntawm Tsom Fwv Nrub Nrab Teb Chaw hais txog pej xeem cov cai (Federal civil rights laws) thiab tsis ciav-cais leejtwg vim nws hom neeg, nqaij tawv, lub tebchaws tuaj, hnub nyoog, kev tsis taus, los yog poj niam txiv.

Sumusunod ang Psychological Service Associates, Inc. sa mga naaangkop na Pederal na batas sa karapatang sibil at hindi nandidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan o kasarian

Psychological Service Associates, Inc. è conforme a tutte le leggi federali vigenti in materia di diritti civili e non pone in essere discriminazioni sulla base di razza, colore, origine nazionale, età, disabilità o sesso.

Psychological Service Associates, Inc. tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính.

Psychological Service Associates, Inc. ਲਾਗੂ ਸੰਘੀ ਨਾਗਿਰਕ ਹੱਕ� ਦੇ ਕਾਨੰ ੂਨ� ਦੀ ਪਾਲਣਾ ਕਰਦੀ ਹੈ ਅਤੇ ਨਸਲ, ਰੰਗ, ਰਾਸ਼ਟਰੀ ਮੂਲ, ਉਮਰ, ਅਸਮਰਥਤਾ, ਜ� ਿਲੰਗ 'ਤੇ ਅਧਾਰ 'ਤੇ ਿਵਤਕਰਾ ਨਹ� ਕਰਦੀ ਹੈ।

Psychological Service Associates, Inc. ametimiza mahitaji ya sheria za serikali kuu na hana ubaguzi wa kikabila, rangi, asili, umri, ilemavu ama jinsia.