HIPPA Disclosure Statement

Please Review It Carefully

WHO WILL FOLLOW THIS NOTICE. This notice describes the information privacy practices followed by this practice, professionals, staff and other office personnel including any practitioner who might provide "call coverage" for me.

YOUR HEALTH INFORMATION: This notice applies to the information and records I have about your health, health status, and the services you receive from this practice. I am required by HIPAA law to give you this notice. It will tell you about the ways in which I may use and disclose health information about you and describes your rights and

HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU. By State law and the ethics of our mental health professions, I must have your written, signed Consent to use and disclose health information for the following purposes:

For Treatment. I use health information about you to provide you with clinical services. I may disclose health information about you to office staff or other personnel who are involved in taking care of you and your health.

For Payment. I may use and disclose health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or a third party. It is my policy to release only diagnoses, date, and type of service when I have your consent to bill third party payers. If a payer requests more information, I will request your authorization for that disclosure.

For Health Care Operations. I may use health information about you in order to run the practice and make sure you receive quality care: i.e. Appointment Reminders. I may contact you as a reminder that you have an appointment although this is not routine. Please notify me if you do not wish to be contacted for appointment reminders, or if there are restrictions you want to make about such contact.

You may revoke your Consent at any time by giving me written notice. Your revocation will be effective when I receive it, but it will not apply to any uses and disclosures that occurred before that time.

If you are receiving Substance Abuse Treatment Federal and State law require your written Authorization each time I release health information. The Authorization will specify who is to receive the information, the 2 purpose of the release of information, and a time period after which the Authorization will terminate. You may modify or revoke an authorization at any time. However, if I am unable to fulfill requirements related to treatment, payment or health care operations, I may choose to discontinue providing you with health care treatment and services.

SPECIAL SITUATIONS I may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:

To Avert a Serious Threat to Health or Safety. Based on professional judgment, I may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Required By Law. Based on professional judgment, I will disclose health information about you when required to do so by federal, state or local law. Disclosures may be compelled by DHHS for compliance and enforcement purposes

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, I may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, I may also disclose health information about you in response to a subpoena. Such disclosures would be based on professional judgment and I will inform you is this situation arises.

Law Enforcement. I may release health information if required to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

Family and Friends. In situations where you are not capable of giving authorization (because you are not present or due to your incapacity or medical emergency), I may, using professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, I would disclose only health information relevant to the person's involvement in your care. For example, if you were in a mental health crisis, I might involve a family member or friend in helping you get to an appropriate care facility.

Additional disclosures are permitted under HIPAA regulation. HIPAA permits additional disclosures. These additional disclosures will not be made by this practice without your authorization; and they may be contrary to state law. However, once information leaves this practice and becomes part of any data resource it is beyond my control, HIPAA permits disclosure in the following circumstances:

Research. I do not participate in research projects in anyway without informing clients. Health information about you can be used for research projects that are subject to a special approval process.

Military. Veterans. National Security and Intelligence. If you are or were a member of the armed forces, or part of the national security or intelligence communities, military command or other government authorities may require the release of health information about you. HIPAA also permits release of information about foreign military personnel to the appropriate foreign military authority.

Workers' Compensation. Health information about you may be released for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. Health information about you may be disclosed for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, nonaccidental physical injuries, reactions to medications or problems with products.

Health Oversight Activities. Health information about you may be disclosed to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws. vvInformation Not Personally Identifiable. Health information about you may be disclosed in a way that does not personally identify you or reveal who you are however I generally do not participate situation that this applies



This practice will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. I must obtain your Authorization separate from any Consent I may have obtained from you. If you give Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, I will no longer use or disclose information about you for the reasons covered by your written Authorization, but cannot take back any uses or disclosures already made with your permission.

If I have HIV or substance abuse information about you, I cannot release that information without a special signed, written authorization (different than the Authorization and Consent mentioned above) from you. In order to disclose these types of records for purposes of treatment, payment or health care operations, I will require a special written authorization that complies with the law governing HIV or substance abuse records.



You have the following rights regarding health information I maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy your health information, such as clinical and billing records. You do not have the right to inspect and copy psychotherapy notes or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. If you are a member of couple you do not have the right to inspect and copy your health information without the written permission of your spouse or partner as the records belong to the couple.

You must submit a written request to the designated privacy contact in order to inspect and/or copy your health information. If you request a copy of the information, I will charge a fee plus hourly rates for the costs of copying, mailing or other associated supplies.

I may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such review is required, by law I will select a licensed health care professional to review your request and my denial. The person conducting the review will not be the person who denied your request, and I will comply with the outcome of the review.

Right to Amend. If you believe health information I have about you is incorrect or incomplete, you may ask to amend the information.

You have the right to request an amendment when this office keeps the information.

To request an amendment, complete and submit a clear statement of the amendment you request to the designated privacy contact, me.

I may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, I may deny your request if you ask me to amend information that: 1. I did not create, unless the person or entity that created the information is no longer available to make the amendment, 2. Is not part of 4 the health information that I keep, 3. You would not be permitted to inspect and copy it, 4. Is accurate and complete

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures I made of clinical information about you for purposes other than treatment, payment and health care operations.

To obtain this list, you must submit your request in writing to me, the designated privacy contact. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, I may charge you for the costs of providing the list. I will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information I use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information I disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that I not call you at your office, or that I not communicate with a certain family member, no matter what the circumstance.

Right to Request Confidential Communications. You have the right to request that we communicate with you about clinical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you may simply advise me in writing of specific limitations or restrictions you want placed on communications with you. I will not ask you the reason for your request. I will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us for a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact designated privacy contact.

CHANGES TO THIS NOTICE I reserve the right to change this notice, and to make the revised or changed notice effective for clinical information I already have about you as well as any information I receive in the future. I will post a summary of the current notice in the office with its effective date clearly shown at the top. You are entitled to a copy of the notice currently in effect.



If you believe your privacy rights have been violated, you may file a complaint with me or with the Secretary of the Department of Health and Human Services. To file a complaint with me, write to me as the designated privacy contact. You will not be penalized for filing a complaint

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