THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures for Treatment, Payment, and Health Care Operations
We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
“PHI” refers to information in your health record that could identify you.
“Treatment, Payment, and Health Care Operations”
“Treatment” is when we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another therapist.
“Payment” is when we obtain reimbursement for your health care. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
“Health Care Operations” are activities that relate to the performance and operations of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
“Use” applies only to activities within the office such as sharing, employing, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of the office such as releasing, transferring, or providing access to information about you to other parties.

Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing any Psychotherapy Notes.

“Psychotherapy Notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

Uses and Disclosures with Neither Consent nor Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse – If we have reason to suspect that a child has been injured as a result of physical, mental or emotional abuse or neglect or sexual abuse, we must report the matter to the appropriate authorities as required by law.

Adult and Domestic Abuse – If we have reasonable cause to believe that an adult is being or has been abused, neglected or exploited, or is in need of protective services, we must report this belief to the appropriate authorities as required by law.

Health Oversight Activities – we may disclose PHI to the State Governmental Regulatory Boards if necessary for a proceeding before the Board.

Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about the professional services we provide you and/or the records thereof, such information is privileged under the state law, and we will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

Serious Threats to Health or Safety – If we believe that there is a substantial likelihood that you have threatened an identifiable person, and that you are likely to act on that threat in the foreseeable future, we may disclose information in order to protect that individual. If we believe that you present an imminent risk of serious physical harm or death to yourself, we may disclose information in order to initiate hospitalization or to family members or others who might be able to protect you.

Worker’s Compensation – we may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work related injuries or illness without regard to fault.

Patient’s Rights and Therapist’s Duties

Patient’s Rights:
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are being seen. On your request we will send your bills to another address.)
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in the mental health and billing records used to make decisions about you for as long as PHI is maintained in the record. The therapist may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.

Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. The therapist may deny your request. On your request, the therapist will discuss with you the details of the amendment process.

Right to Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, the therapist will discuss with you the details of the accounting process.

Right to Paper Copy – You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.

Therapist’s Duties:
We are required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practice with respect to PHI.

We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
If we revise our policies and procedures, we will mail you a notice explaining the changes.

Questions and Complaints
If you have questions about this notice, disagree with a decision your therapist makes about access to your records or have other concerns about our privacy rights you may contact your therapist at the office to discuss your concerns.
If you believe that your privacy rights have been violated and wish to file a complaint you may send your written complaint to the therapist at the office.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Your therapist can provide you wi
th the appropriate address upon request. You have specific rights under the Privacy Rule. The therapists in this office will not retaliate against you for exercising your right to file a complaint.

This notice went into effect on April 14, 2003 and is reviewed and updated annually.