This notice applies to anybody who utilizes my services and is a client under my care. 

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I am required by law to maintain the privacy of your protected health information (PHI) and to provide you with notice of your privacy rights and my legal duties and privacy practices with respect to your PHI. I am required to abide by the terms of this notice with respect to your PHI but reserve the right to change the terms of this notice and make the new notice provisions effective for all PHI that I maintain. I will provide you with a copy of the revised notice made available through your client portal and as well as in office.

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UNDERSTANDING YOUR PERSONAL HEALTH INFORMATION

Each time you visit a hospital, physician, mental health professional, or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, in the case of a mental health professional, psychotherapy notes, and a plan for future care or treatment. This information, often referred to as your health or medical record serves as a:

• Basis for planning your care and treatment

• Means of communication among the many health professionals who contribute to your care

• Legal document describing the care you received

• Means by which you or a third-party payer can verify that the services billed were actually provided

• A tool for educated health professionals

• A source of date for medical research

• A source of information for public health officials charged with improving the health of the nation

• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

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Understanding what is in your record and how your information is used helps you to:

• Ensure its accuracy

• Better understand who, what, when where, and why others may access your health information

• Make more informed decisions when authorizing disclosure to others

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YOUR HEALTH INFORMATION RIGHTS

Although your health record is the physical property of my practice, the information belongs to you. You have the following privacy rights:

1. The right to request restrictions on the use and disclosure of your PHI to carry out treatment, payment, or other health care operations.

   • You should note that I am not required to agree to be bound by any restrictions that you request, but I am bound by each restriction to which I agree.

2. In connection with any patient directory, the right to request restrictions on the use and disclosure of your name, the location of this office, description of your condition and your religious affiliation.

3. To receive confidential communication of your PHI unless I determine that such disclosures would be harmful to you.

4. To inspect and copy your PHI unless I determine in the exercise of my professional judgment that the access requested is reasonably likely to endanger your life or physical safety or emotional safety or that of another person.

   • You may request copies of your PHI by providing me with a written request for such copies. I will provide you with copies within 10 business days of your request at my office. You may be charged a reasonable fee to cover the cost of meeting this request.

5. To amend your PHI upon your written request to me setting forth your reasons for the requested amendment. I have the right to deny the request if the information is complete or has been created by another entity.

   • I am required to act on your request and to amend your PHI within 60 calendar days but this deadline may be extended for another 30 calendar days upon written notice to you. If I deny your requested amendment, I will provide you with written notice of my decision and the basis for my decision. You will then have the right to submit a written statement disagreeing with my decision which will be maintained with your PHI. If you do not wish to submit a statement of disagreement, you may request that I provide your request for amendment and my denial with any future disclosures of your PHI.

6. Upon request to receive an accounting of disclosures of your PHI within the past 6 years of your request of an accounting, I am required to act on your request for accounting within 60 calendar days but this deadlines may be extended for 30 calendar days upon written notice to you of the reason for the delay and the date by which I will provide the accounting. You are entitled to 1 accounting in any 12 month period free of charge. For any subsequent request in a 12 month period, you will be charged a reasonable fee to cover the cost of meeting your request. Disclosures that are exempted from the accounting requirements include the following:

   • Disclosures necessary to carry out treatment, payment, and health care operations

   • Disclosures made upon your request

   • Disclosures made pursuant to your authorization

   • Disclosures made for national security or intelligence purposes

   • Permitted disclosures to correctional institutions or law enforcement officials

   • Disclosures that are part of a limited data set used for research, public health, or health care operations

7. To receive a paper copy of this privacy notice even if you agreed to receive a copy electronically.

8. The right to complain to me and to the Secretary of the U.S. Department of Health and Human Services (HHS) if you believe your privacy rights have been violated. You may submit your complaints to me in writing setting out the alleged violation. I am prohibited by law from retaliating against you in any way for filing a complaint with me or DHHS.

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USES AND DISCLOSURES OF PHI

Your written authorization is required before I can use or disclose my psychotherapy notes which are defined as my notes documenting or analyzing the contents of our conversations during our counseling sessions and that are separated from the rest of your clinical file.  Psychotherapy notes include counseling session start & stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

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It is my policy to protect the confidentiality of your PHI to the best of my ability and to the extent permitted by law.  There are times however when use or disclosure of your PHI including psychotherapy notes is permitted or mandated by law even without your authorization.

Situations where I am not required to obtain your consent or authorization for use or disclosure of your PHI psychotherapy notes include the following circumstances:

• By me for treatment, payment, or health care operations that relate to you. For Example: A bill may be sent to you or a third-party payer.  The information on or accompanying the bill may include information that identifies you as well as your diagnosis, procedures, and supplies used.

• In the event of an emergency to any treatment provider who provides emergency treatment to you.

• To defend myself in legal action or other proceeding brought by you against me.

• When required by the Secretary of the Department of Health and Human Services in an investigation to determine my compliance with privacy rules.

• When required by law in so far as the use or disclosure complies with and is limited to the relevant requires of such law. Examples: to a public health authority or other government authority authorized by law to receive reports of child abuse or neglect

• If I reasonably believe an adult individual to be the victim of abuse, neglect, or domestic violence, to a governmental authority, including a social services agency authorized by law to receive such reports to the extent the disclosure is required by or authorized by law or you agree to the disclosure and I believe in the exercise of my professional judgment that disclosure is necessary to prevent serious harm to you or other potential victims.  If I make such a report I am obligated to inform you unless I believe informing the adult individual will place the individual at risk of serious injury.

• In the course of any judicial or administrative proceeding in response to:

  1. An order of a court or administrative tribunal so long as only the PHI expressly authorized by such order is disclosed or

  2. A subpoena, discovery request or other lawful process, that is not accompanied by an order of a court or administrative tribunal so long as reasonable efforts are made to give you notice that your PHI has been requested or reasonable efforts are made to secure a qualified protective order by the person requesting the PHI.

  3. Child custody cases and other legal proceedings in which your mental health or condition is an issue are the kinds of suits in which your PHI may be requested.

  4. In addition I may use your PHI in connection with a suit to collect fees for my services.

  5. In compliance with a court order or court ordered warrant, or subpoena or summons issued by a judicial officer, a grand jury summons or subpoena, a civil or an authorized investigative demand or similar process authorized by law provided that the information sought is relevant and material to a legitimate law enforcement inquiry, the request is specific and limited in scope to the extent reasonable practical in light of the purpose for which the information is sought and de-identified information could not reasonably be used.

  6. To a health oversight agency for oversight activities authorized by law as they may relate to me (i.e. audits, civil, criminal, or administrative investigations, inspections, licensure or disciplinary actions, civil, administrative, or criminal proceedings or actions).

  7. To a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law.

  8. To funeral directors consistent with applicable law as necessary to carry out their duties with respect to the decedent.

  9. To the extent authorized by and the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

  10. If use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

  11. To a public health authority that is authorized by law to collect or receive such information for the purposes of preventing or controlling a disease, injury or disability, including, but not limited to, the reporting of disease, injury, vital events such as birth, death, and the conduct of public surveillance, public health investigations, and public health interventions.

  12. To a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition, if the covered entity or public health authority is authorized by law to notify such persons as necessary in the conduct of a public health intervention or investigation.

  13. To a public health authority or other appropriate governmental authority authorized by law to receive reports of child abuse or neglect.

  14. To a law enforcement official if I believe in good faith that the PHI constitutes evidence of criminal conduct that occurs on my premises.

  15. Using my best judgment to a family member or other relative or close personal friend or any other person you identify, I may disclose PHI that is relevant to that person’s involvement in your care or payment related to your care.

  16. To authorized federal officials for the conduct of lawful intelligence, counterintelligence, and other national security activities authorized by the National Security Act and implementing authority.

  17. To Business Associates under a written agreement requiring Business Associates to protect the information. Business Associates are entities that assist with or conduct activities on my behalf including individuals or organizations that provide legal, accounting, administrative and similar functions.

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I may contact you with appointment reminders or information about treatment alternatives or other health related benefits and services that may be of help to you.

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If you have any questions and would like additional information you should bring this to my attention at the first opportunity.  I am the designated Privacy Officer for my practice and will be glad to respond to your questions and request for information. 

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