Notice of Privacy Practices (HIPAA)

EFFECTIVE DATE OF THIS NOTICE This notice went into effect on February 28, 2023

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE

REVIEW IT CAREFULLY.

I. OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We are committed

to protecting your health information about you. We create a record of the care and services you

receive from our facility. We need this record to provide you with quality care and to comply with certain

legal requirements. This notice applies to all of the records of your care generated by this mental

health care practice. This notice will tell you about the ways in which we may use and disclose

health information about you. We also describe your rights to the health information we keep about

you, and describe certain obligations we have regarding the use and disclosure of your health

information. We are required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of our legal duties and privacy practices with respect to health

information.

• Follow the terms of the notice that is currently in effect.

• We can change the terms of this Notice, and such changes will apply to all information we

have about you. The new Notice will be available upon request, in our office, and on our

website.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that we use and disclose health information. For

each category of uses or disclosures, We will explain what we mean and try to give some examples.

Not every use or disclosure in a category will be listed. However, all of the ways we permitted

to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow

healthcare providers who have direct treatment relationship with the patient/client to use or

disclose the patient/client’s personal health information without the patient’s written

authorization, to carry out the health care provider’s own treatment, payment or health care

operations. We may also disclose your protected health information for the treatment activities of

any healthcare provider. This, too, can be done without your written authorization. For example, if a

clinician were to consult with another licensed health care provider about your condition, we

would be permitted to use and disclose your personal health information, which is otherwise

confidential, in order to assist the clinician in diagnosis and treatment of your mental health

condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because

therapists and other health care providers need access to the full record and/or full and complete

information in order to provide quality care. The word “treatment” includes, among other things,

the coordination and management of health care providers with a third party, consultations

between health care providers, and referrals of a patient for health care from one health care

provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in

response to a court or administrative order. We may also disclose health information about your

child in response to a subpoena, discovery request, or other lawful processes by someone else

involved in the dispute, but only if efforts have been made to tell you about the request or to

obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes. We do keep “psychotherapy notes” as that term is defined in 45 CFR

§ 164.501, and any use or disclosure of such notes requires your Authorization unless the

use or disclosure is:

a. For our use in treating you.

b. For our use in training or supervising mental health practitioners to help them improve

their skills in group, joint, family, or individual counseling or therapy.

c. For our use in defending myself in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate my compliance

with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the

psychotherapy notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes. As psychotherapists, we will not use or disclose your PHI for

marketing purposes.

3. Sale of PHI. As psychotherapists, we will not sell your PHI in the regular course of our

business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.

Subject to certain limitations in the law, we can use and disclose your PHI without your

Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies

with and is limited to the relevant requirements of such law.2. 3. 4. 5. 6. 7. For public health activities, including reporting suspected child, elder, or dependent adult

abuse, or preventing or reducing a serious threat to anyone’s health or safety.

For health oversight activities, including audits and investigations.

For judicial and administrative proceedings, including responding to a court or

administrative order, although my preference is to obtain authorization from you before

doing so.

For law enforcement purposes, including reporting crimes occurring on my premises.

To coroners or medical examiners, when such individuals are performing duties

authorized by law.

For research purposes, including studying and comparing the mental health of patients

who received one form of therapy versus those who received another form of therapy for

the same condition.

8. Specialized government functions, including, ensuring the proper execution of military

missions; protecting the President of the United States; conducting intelligence or

counter-intelligence operations; or, helping to ensure the safety of those working within

or housed in correctional institutions.

9. For workers’ compensation purposes. Although my preference is to obtain authorization

from you, we may provide your PHI in order to comply with workers’ compensation laws.

10 Appointment reminders and health-related benefits or services. We may use and disclose

your PHI to contact you to remind you that you have an appointment. We may also

use and disclose your PHI to tell you about treatment alternatives, or other healthcare

services or benefits.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY

TO OBJECT.

1. Disclosures to family, friends, or others. We may provide your PHI to a family member,

friend, or other persons that you indicate is involved in your care or the payment for your

health care, unless you object in whole or in part. The opportunity to consent may be

obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. 2. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to

ask us not to use or disclose certain PHI for treatment, payment, or health care

operations purposes. We are not required to agree to your request, and we may say “no” if we

believe it would affect your health care.

The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have

the right to request restrictions on disclosures of your PHI to health plans for payment or

health care operations purposes if the PHI pertains solely to a health care item or a health

care service that you have paid for out-of-pocket in full.3. The Right to Choose How We Send PHI to You. You have the right to ask us to contact you

in a specific way (for example, at home or office phone) or to send mail to a different

address, and we will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you

have the right to get an electronic or paper copy of your medical record and other

information that we have about you. We will provide you with a copy of your record, or a

summary of it, if you agree to receive a summary, within 30 days of receiving your

written request, and we may charge a reasonable, cost-based fee for doing so.

5. The Right to Get a List of the Disclosures We Have Made. You have the right to request a

list of instances in which we have disclosed your PHI for purposes other than treatment,

payment, or healthcare operations, or for which you provided us with authorization. We

will respond to your request for an accounting of disclosures within 60 days of receiving

your request. The list we will give you will include disclosures made in the last six years

unless you request a shorter time. We will provide the list to you at no charge, but if you

make more than one request in the same year, we will reserve the right to charge you a reasonable cost-based

fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your

PHI, or that a piece of important information is missing from your PHI, you have the

right to request that we correct the existing information or add the missing information. We

may say “no” to your request, but we will tell you why in writing within 60 days of

receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a

paper copy of this Notice, and you have the right to get a copy of this notice by e-mail.

And, even if you have agreed to receive this Notice via e-mail, you also have the right to

request a paper copy of it.

Acknowledgment of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have

certain rights regarding the use and disclosure of your protected health information. By checking

the box below, you are acknowledging that you have received a copy of the HIPAA Notice of

Privacy Practices.