Notice of Privacy Practices
This Notice is Effective as of April 14, 2003.
This Notice serves to explain the ways in which your Protected Health Information
(PHI) must be managed. PHI is information about you, including basic demographic
information, that may identify you and that relates to your past, present, or future physical or
mental health. This Notice will also serve to inform you of your rights and my obligations in the
use of any disclosure of medical and mental health information.
It is understood that information about you and your health is personal. Each time you
visit any doctor's office, hospital, or clinic, information is collected about you and your physical
or mental health. A record of the care and services that you receive goes into your health care record. This record
is needed to comply with certain legal requirements and it helps to provide you with quality care.
Mental health information that identifies you is kept private and confidential. Anyone
employed or contracted by the counseling office must abide by state and federal guidelines of
You must be given this Notice of legal duties and privacy practices regarding PHI
information about you. I will not disclose PHI about you without your written authorization,
except as described in this Notice and as further outlined in the Informed Consent for Counseling
"Confidentiality Exceptions" Section.
Examples of how PHI may be used and disclosed under this Notice
For Treatment: Your PHI may be used in order to conduct a current assessment of your
problems; to obtain previous client records, when applicable; to create and carry out a treatment
plan; to talk with other health care professionals who are also treating you, such as your family
doctor, medical specialists, or psychiatrist. You may be referred to other professionals or services
which I cannot provide. When this happens, I need to tell them things about you and your
condition. I will receive back their findings and impression/recommendations and those will go
into your record.
For Payment: Your PHI is used to create a billing statement. It may also be used to inform
insurance companies and third party payers with regards to billing for services.
For Healthcare Operations: Your PHI may be used to run the business operation of this office,
and to monitor the performance of any mental health provider or office staff involved with
record keeping for the purpose of improving the quality and effectiveness of services rendered.
Personal Communications: Your PHI may be part of contacts made to schedule counseling
appointments, follow-up on voice mail or e-mail questions or requests, to mail written
documentation of client visits through billing statements, or for the purpose of notifying you of
upcoming counseling groups or providing informative and educational information or referrals.
Treatment Alternatives: PHI about you may be released by me for your care in the case that the
therapist recommends alternative treatment such as partial hospitalization or in-patient treatment,
or any other treatment option or alternative that may be of interest or benefit to you.
Food and Drug Administration: PHI about you may be disclosed to the FDA or its agents
relative to adverse events with respect to drugs, foods, supplements, products and product
defects, or post-marketing surveillance information to enable product recalls, repairs, or
Individuals Involved in Your Care or Payment for Your Care: Other health care professionals
involved in your care including family physicians, psychiatrists, in-patient hospital programs,
drug and alcohol treatment programs, community support services, as well as family members,
close friends or relatives that you designate may be given PHI relevant to your care and
Research: PHI about you may be given to researchers when their research has been approved by
an institution review board that has reviewed the research proposal and established protocols to
ensure privacy or your information.
Authorization to Disclose PHI
If your PHI is going to be used for any purpose other than those described, I need your
permission on an authorization form. It is not expected that this will be needed very often. If
you do agree to allow your PHI to be used or disclosed by me, you have the right to revoke the
agreement at any time.
Uses and disclosures that do not require your consent or authorization
Required By Law: I must disclose PHI about you when required by federal, state or local law in
the following instances:
Avert a Serious Threat of Health or Safety: PHI may be disclosed by me about you when
necessary to prevent a serious threat to your health and safety, or the health and safety of others.
The information may be disclosed to public health or legal authorities charged with preventing or
controlling disease, injury, or disability.
Victims of Abuse, Neglect, Exploitation, or Domestic Violence: I am required to disclose PHI to
government authority, such as social service or protective services agencies, if it is suspected that
you are the victim or perpetrator of abuse, neglect, exploitation, or domestic violence in order to
prevent serious harm to you or someone else.
Health Oversight Activities: I may disclose PHI about you to an oversight agency for activities
authorized by law. These oversight activities include audits, investigations, and inspections, as
necessary for licensure and the government to monitor the mental health care system under state,
federal, and local laws.
Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, I may
disclose PHI about you in response to a court or administrative order, a subpoena, or a discovery
request, but only if efforts have been made to tell you about the request or to obtain an order
protecting the information requested.
Law Enforcement: PHI may disclosed about you for law enforcement purposes as required by
law or in a response to a valid subpoena, court order, warrant, summons or similar process; to
identify or locate a suspect, fugitive, material witness, or missing person; or about the victim of a
crime if, under certain limited circumstances I am unable to obtain the person’s agreement; about
a death I believe may be the result of criminal conduct; in emergency circumstances to report a
crime, the location of a crime or victims, or the identity, description or location of the person
who committed the crime.
Coroners, Medical Examiners and Funeral Directors: PHI may be released about you to a
coroner or medical examiner by me. This may be necessary, for example, to identify a deceased
person or determine the cause of death. PHI may also be released to funeral directors, to carry
out their duties.
National Security and Intelligence Activities: PHI may be released about you to authorized
federal officials for intelligence, counterintelligence, and other national security activities
authorized by the law by me.
Protective Services for the President and Others: I may disclose PHI about you to authorize
federal officials so they may provide protection to the President, other authorized persons or
foreign heads of state or to conduct special investigations.
Correctional Institutions: If you are or become an inmate of a correctional institution, PHI
necessary for your health and the health and safety of others may be disclosed to the institution
or its agents by me.
Your Health Information Rights
You have the following rights with respect to PHI about you:
Obtain a Paper Copy of This Notice Upon Request: You may request a paper copy of this
notice at any time. Even if you have agreed to receive this Notice electronically, you are still
entitled to a paper copy of the Notice.
Inspect and Obtain a Copy of PHI: You have the right to access and copy PHI about you
contained in a designated record set for as long as the counseling office maintains the record.
The designated record will contain a diagnosis, treatment plan, progress and billing summary. To
inspect or copy you PHI you must send a written request to this counseling office. You will
be charged a fee for the cost of copying, mailing, and other supplies that are necessary to respect
your request. Your request may be denied to inspect and copy your PHI in certain limited
circumstances. If you are denied access to PHI about you, you may request that the denial be
Request an Amendment of PHI: I you feel that PHI in your mental health record is incomplete
or incorrect; you may request that it be amended. To request an amendment you must send a
written request to the counseling office. In addition, you must include a reason that supports
your request. In certain cases, your request may be denied for amendment. If you are denied, you
have the right to file a statement of disagreement with the decision and you will be provided with
a rebuttal to your statement.
Receive an Accounting of PHI: You have the right to receive an accounting of the disclosures
that have been made about you after April 14, 2003. To request an accounting, you must submit
the request in writing to the therapist at this counseling office. Your request must specify the
time. You will be notified of any costs involved. You have the right to modify or withdraw your
request at that time. I am not required to agree with your request.
Request Communications of PHI by Alternative Means, At Alternative Locations, or Right to
Request Restrictions and Confidentiality on PHI: Example: You may request that the therapist
on your cell phone, that messages not be left on your home or work voice mail, that the therapist
not identify herself when calling you if someone else answers the phone, that no identifying
information appear on the outside of written communications. Your request must be in writing
and state how and when you would like to be contacted.
Changes to this Notice
I reserve the right to change my practices and this Notice and to make the new Notice
effective for all PHI maintained in my office. Upon request I will provide a revised PHI to you.
If you believe your privacy rights have been violated, you may file a complaint with the
therapist and/or with the Secretary of the Department of Health and Human Services. All
complaints must be submitted in writing. You will not be penalized or discriminated against
for filing a complaint.