Are mental health professionals bound by the same rules as other HIPAA-covered entities?

by | Jul 3, 2023 | HIPAA News and Advice

Yes, mental health professionals are generally bound by the same rules as other HIPAA-covered entities, which include maintaining the confidentiality and privacy of patients’ PHI, implementing appropriate security measures, obtaining patient consent for disclosures, providing patients with notice of their privacy rights, and adhering to the requirements outlined in HIPAA to ensure the safeguarding of sensitive patient information in mental health treatment.

HIPAA-Related Roles/ResponsibilitiesExplanation
Mental health professionals bound by HIPAA rulesThey must adhere to the same regulations as other entities covered by HIPAA.
Regulations cover PHI confidentiality and securityHIPAA governs the protection of patients’ PHI in mental health practices.
Covered entities under HIPAAMental health professionals are considered covered entities, obligated to follow the HIPAA Privacy Rule and Security Rule.
HIPAA Privacy Rule Standards for PHIThe HIPAA Privacy Rule sets criteria for PHI protection, disclosures, and usage, generally requiring patient consent for most disclosures.
HIPAA Security Rule safeguards for ePHIThe HIPAA Security Rule mandates safeguards to secure electronic PHI (ePHI) against unauthorized access and disclosure.
Applies to various forms of health informationAll types of individually identifiable health data, including written, oral, and electronic formats, fall under HIPAA’s scope.
Consent for PHI disclosure is often requiredExcept for treatment, payment, or healthcare operations, a patient’s written consent is usually needed for PHI disclosure.
Providing patients with Notice of Privacy PracticesMental health professionals must offer patients a notice explaining privacy rights and the intended use of their PHI.
Implementation of safeguards for ePHIAdministrative, physical, and technical measures are needed to safeguard ePHI, with regular risk assessments and security updates.
Collaboration with other healthcare providers allowedSharing patient data with other providers is permissible for treatment, payment, and healthcare operations, with minimum necessary information shared.
Duty to report threats of harmMental health professionals must report threats of harm, even if it involves disclosing PHI without patient consent.
Compliance requirements for business associatesBusiness associates handling PHI must comply with HIPAA and sign business associate agreements (BAAs).
Breach notification proceduresBreaches of PHI require specific notification procedures, varying based on the number of affected individuals.
Penalties for Non-complianceViolating HIPAA regulations can lead to penalties and fines, determined by the severity of the breach.
Ongoing training and educationContinuous learning is necessary for staying updated on HIPAA regulations and ensuring compliance with mental health practices.
Balancing patient privacy with compassionate careMental health professionals adhere to patient consent, clear notices, and security measures while providing empathetic care.
Table: HIPAA-Related Roles and Responsibilities of Mental Health Professionals

Under HIPAA, mental health professionals are considered covered entities, which means they are legally obligated to comply with the HIPAA Privacy Rule and the Security Rule. The HIPAA Privacy Rule establishes standards for the protection of PHI, including the disclosure and use of such information, while the HIPAA Security Rule outlines the necessary safeguards to protect electronic PHI (ePHI) from unauthorized access, use, and disclosure. HIPAA’s regulations apply not only to medical records but also to any form of individually identifiable health information, whether it is written, oral, or electronic. The objective of HIPAA’s regulations revolves around maintaining patient confidentiality. Mental health professionals must obtain patients’ written consent before disclosing any PHI, except in situations where sharing information is needed for the patient’s treatment, payment, or healthcare operations. This consent should be specific and clear, outlining the purpose of the disclosure and the entities involved. Importantly, patients have the right to revoke this consent at any time.

Mental health professionals are also required to provide patients with a Notice of Privacy Practices (NPP) that explains their privacy rights and how their PHI will be used and disclosed. Patients should receive this notice at the initiation of treatment, and any subsequent updates should also be communicated to them. The NPP should include information about the patient’s rights to access their PHI, request amendments, and file complaints if they suspect any violations of their privacy rights.

The HIPAA Security Rule adds an extra layer of protection by requiring that mental health professionals implement administrative, physical, and technical safeguards to ensure the security of ePHI. These safeguards may include access controls, encryption, audit logs, and regular risk assessments to identify vulnerabilities and address them promptly. Mental health professionals must stay current with advancements in technology and security practices to ensure that their electronic systems are up-to-date and compliant. In cases where mental health professionals work in conjunction with other healthcare providers, such as collaborating with primary care physicians or specialists, sharing patient information is permissible for the purpose of treatment, payment, and healthcare operations. However, it is necessary to exercise caution and only disclose the minimum necessary information to achieve the intended purpose. Careful consideration must be given to maintaining the privacy and confidentiality of patient’s mental health records, which can often contain sensitive information.

Mental health professionals also must report potential harm to patients or others. HIPAA’s regulations do not prohibit the disclosure of PHI when there is a threat of harm, such as a patient expressing an intent to harm themselves or others. Mental health professionals have an ethical and legal obligation to take necessary steps to ensure the safety of all parties involved, even if it involves disclosing PHI without patient consent. However, these disclosures should be limited to the individuals or entities directly involved in preventing harm. Compliance with HIPAA extends to business associates as well—entities that handle PHI on behalf of mental health professionals, such as billing companies or electronic health record vendors. Mental health professionals must enter into business associate agreements (BAAs) with these entities, outlining their responsibilities and obligations to protect patient information in accordance with HIPAA’s regulations.

In the event of a breach of PHI, mental health professionals are required to follow specific breach notification procedures. If the breach affects 500 or more individuals, the Department of Health and Human Services (HHS) must be notified within a specific timeframe. For breaches involving fewer than 500 individuals, the affected patients must be notified within a reasonable timeframe. Non-compliance with HIPAA regulations can result in penalties, including fines that vary based on the nature and extent of the HIPAA violation. Mental health professionals must actively engage in ongoing HIPAA training and education to ensure an understanding of HIPAA and legislation updates, enabling them to provide high-quality care while safeguarding patients’ privacy and maintaining legal compliance.


Mental health professionals play an important role in preserving the confidentiality and security of patients’ PHI, in line with the regulations stipulated by HIPAA. Adhering to these regulations requires a deep understanding of the HIPAA Privacy Rule and Security Rule, ensuring the appropriate use and safeguarding of PHI in both physical and electronic formats. By maintaining patient consent, providing clear notices of privacy practices, and implementing appropriate security measures, mental health professionals can adhere to their ethical responsibilities while offering effective and compassionate care to those in need.

HIPAA Covered Entity Topics

What is the definition of a HIPAA-covered entity?
How does an organization determine if it is a HIPAA-covered entity?
Are all healthcare providers considered HIPAA-covered entities?
What obligations does an entity covered by HIPAA have concerning patient data?
Do insurance companies fall under the category of entities covered by HIPAA?
What is a covered entity under HIPAA?
Who would not be considered a covered entity under HIPAA?
Is an employer a covered entity under HIPAA?
Who should HIPAA complaints be directed to within the covered entity?
What are the penalties for a HIPAA-covered entity that breaches patient confidentiality?
Are health technology companies automatically considered HIPAA-covered entities?
What distinguishes a HIPAA entity from non-covered entities?
Can a HIPAA-covered entity share medical records with another such entity without patient consent?
How often should HIPAA-covered entities review their compliance procedures?
What types of training must employees of an entity covered by HIPAA undergo?
How do entities covered by HIPAA handle data breaches?
What is the role of a privacy officer in a HIPAA-covered entity?
Are dental practices considered HIPAA-covered entities?
Can a patient sue a HIPAA-covered entity for a data breach?
How are HIPAA-covered entities audited for compliance?
What are the reporting obligations of a HIPAA entity in case of data exposure?
How do third-party vendors interact with HIPAA-covered entities?
Can a business associate be considered a HIPAA-covered entity?
How should a HIPAA entity respond to unauthorized access to protected health information?
What security measures must entities covered by HIPAA implement?
Are there exemptions for certain types of entities covered by HIPAA?
How long must a HIPAA-covered entity retain medical records?
What patient rights are recognized by entities covered by HIPAA concerning their personal data?
Are telemedicine platforms typically classified as HIPAA-covered entities?
What distinguishes business associates from HIPAA-covered entities?
How can patients file complaints against a HIPAA entity?
What is the significance of the Notice of Privacy Practices for a HIPAA-covered entity?
How do international medical tourism practices intersect with HIPAA-covered entities?
Are there specific encryption standards that a HIPAA-covered entity must adhere to?
How do federal and state laws regarding patient privacy relate to HIPAA-covered entities?
How do HIPAA-covered entities handle minor patient information?
Are pharmacies and drug stores universally categorized as HIPAA-covered entities?
How can a HIPAA-covered entity ensure compliance when integrating new technologies?
What are the key differences between a HIPAA-covered entity and a HIPAA business associate?
Are research institutions always considered HIPAA-covered entities?
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Can cloud service providers be classified as HIPAA-covered entities?
How should a HIPAA entity prepare for an official audit or review?
What documentation is essential for a HIPAA-covered entity’s compliance processes?
How often do regulations impacting HIPAA-covered entities get updated?
Do educational institutions fall under the scope of entities covered by HIPAA?
How do mobile health apps and digital health tools intersect with HIPAA-covered entities?
What is the role of electronic health record systems in a HIPAA-covered entity?
How does the Health Information Exchange (HIE) network impact HIPAA-covered entities?
Are mental health professionals bound by the same rules as other HIPAA-covered entities?
How do mergers and acquisitions impact the status of a HIPAA-covered entity?
Can patients access all their health data held by a HIPAA-covered entity?
Are billing and invoicing data handled differently by entities covered by HIPAA than medical data?
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