Notice of Privacy Practices

Effective Date of This Notice

This notice went into effect on June 2013.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (hereafter, "HIPAA"), you have certain rights regarding the use and disclosure of your protected health information (hereafter, "PHI").

My Pledge Regarding Health Information

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I 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 I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information.

I am required by law to:

• Make sure that PHI that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.

I can change the terms of this Notice, and such changes will apply to all the information I have about you. The new Notice will be available upon request, in my office, and on my website.

How I May Use and Disclose Health Information About You

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am 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 health care 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. I may also disclose your PHI for the treatment activities of any health care 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 PHI, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your health condition. I may also use your PHI for operations purposes, including sending you appointment reminders, billing invoices and other documentation.

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, I may disclose health information in response to a court or administrative order. I may also disclose health information about you or your minor child(ren) 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.

Certain Uses and Disclosures Require Your Authorization

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:

• For my use in treating you.
• 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.
• For my use in defending myself in legal proceedings instituted by you.
• For use by the Secretary of the Department of Health and Human Services (HHS) to investigate my compliance with HIPAA.
• Required by law and the use or disclosure is limited to the requirements of such law.
• Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
• Required by a coroner who is performing duties authorized by law.
• Required to help avert a serious threat to the health and safety of others.

Marketing Purposes: I will not use or disclose your PHI for marketing purposes without your prior written consent.

Sale of PHI: I will not sell your PHI.

Uses and Disclosures That 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:

• Appointment reminders and health related benefits or services.
• When disclosure is required by state or federal law.
• 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.
• 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.
• Specialized government functions.
• For workers' compensation purposes.
• For organ and tissue donation requests.

Your Rights With Respect to Your PHI

• 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.
• The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on the disclosure 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.
• 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.
• The Right to See and Get Copies of Your PHI. You have the right to get an electronic or paper copy of your medical record and other information that I have about you.
• 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.
• 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, you have the right to request that I correct the existing information or add the missing information.
• The Right to Get a Paper or Electronic Copy of this Notice.
• The Right to Choose Someone to Act For You. If you have given someone medical power of attorney or if someone is your legal guardian, that person can make choices about your health information.
• The Right to Revoke an Authorization.
• The Right to Opt out of Communications and Fundraising from our Organization.
• The Right to File a Complaint. You can file a complaint if you feel I have violated your rights by contacting me or by filing a complaint with the HHS Office for Civil Rights.

Changes to This Notice

I can change the terms of this Notice, and such changes will apply to all the information I have about you. The new Notice will be available upon request, in my office and on my website.