NOTICE OF PRIVACY PRACTICES

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, I may disclose health information in
response to a court or administrative order. I may also disclose health information about your
child in response to a subpoena, discovery request, or other lawful process 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. I 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 my use in treating you. b. For my 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 my 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 a psychotherapist, I will not use or disclose your PHI for
marketing purposes.

3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my
business.

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

Subject to certain limitations in the law, I 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. 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.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or
administrative order, although my preference is to obtain an Authorization from you
before doing so.

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

6. To coroners or medical examiners, when such individuals are performing duties
authorized by law.

7. 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 an
Authorization from you, I may provide your PHI in order to comply with workers'
compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose
your PHI to contact you to remind you that you have an appointment with me. I may also
use and disclose your PHI to tell you about treatment alternatives, or other health care
services or benefits that I offer.

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

1. Disclosures to family, friends, or others. I may provide your PHI to a family member,
friend, or other person 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. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to
ask me not to use or disclose certain PHI for treatment, payment, or health care
operations purposes. I am not required to agree to your request, and I may say “no” if I
believe it would affect your health care.

2. 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 I Send PHI to You. You have the right to ask me to contact you
in a specific way (for example, home or office phone) or to send mail to a different
address, and I 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 I have about you. I 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 I may charge a reasonable, cost based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made.You have the right to request a
list of instances in which I have disclosed your PHI for purposes other than treatment,
payment, or health care operations, or for which you provided me with an Authorization.
I will respond to your request for an accounting of disclosures within 60 days of
receiving your request. The list I will give you will include disclosures made in the last 
six years unless you request a shorter time. I will provide the list to you at no charge, but
if you make more than one request in the same year, I will 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 I correct the existing information or add the missing information. I
may say “no” to your request, but I 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 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.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on 06/01/2020
Acknowledgement 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 HIPAA Notice of
Privacy Practices.