Notice ofprivacy practices.

I. My pledge regarding your information

I understand that information about you and the services you receive is personal, and I am committed to protecting it. I create a record of the care and services you receive from me. I need this record to provide quality services and to meet certain legal requirements.

This notice applies to all records created by this practice, whether for clinical and counseling services or for performance work. It explains how I may use and disclose information about you, your rights regarding that information, and my obligations.

I am required by law to:

• Keep protected health information (“PHI”) that identifies you private.
• Give you this notice of my legal duties and privacy practices with respect to your PHI.
• Follow the terms of the notice currently in effect.
• Notify you if a breach occurs that may have compromised the privacy or security of your PHI.
• Provide you with adequate notice of your rights and my legal duties if I create or maintain records protected by 42 C.F.R. Part 2 (federal rules for certain substance use disorder records).

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

II. How I may use and disclose information about you

The categories below describe the ways I may use and disclose PHI, with some examples. Not every use or disclosure in a category is listed, but every way I am permitted to use and disclose information falls within one of these categories.

For treatment, payment, or health care operations. Federal privacy rules allow health care providers who have a direct treatment relationship with a client to use or disclose the client’s PHI without written authorization for the provider’s own treatment, payment, or health care operations. I may also disclose your PHI for the treatment activities of any health care provider without your written authorization. For example, if I consult with another licensed health care provider about your care, I may use and disclose your PHI, which is otherwise confidential, to help with diagnosis and treatment.

If your records are protected under 42 C.F.R. Part 2, certain uses and disclosures that HIPAA permits for treatment, payment, and health care operations are materially limited by the stricter standards of those regulations. Information disclosed under these rules may be redisclosed by the recipient and may no longer be protected by federal privacy rules.

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 complete information to provide quality care. “Treatment” includes, among other things, coordinating and managing care with a third party, consultations between health care providers, and referrals from one health care provider to another.

Lawsuits and disputes. If you are involved in a lawsuit, I may disclose PHI in response to a court or administrative order. I may also disclose PHI 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. Records protected by 42 C.F.R. Part 2, or testimony about their content, will not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless you give specific written consent or a court order is issued in accordance with 42 C.F.R. Part 2.

III. Uses and disclosures that require your authorization

1. Psychotherapy notes. I may keep “psychotherapy notes” as defined in 45 C.F.R. § 164.501. Any use or disclosure of these 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 brought by you;
• for use by the Secretary of Health and Human Services to investigate my compliance with HIPAA;
• required by law, and limited to the requirements of that law;
• required by law for certain health oversight activities relating to the originator of the psychotherapy notes;
• required by a coroner performing duties authorized by law;
• needed to help avert a serious threat to the health and safety of others.

2. Substance use disorder (SUD) counseling notes. I may keep “SUD counseling notes,” which are notes recorded by a substance use disorder provider documenting the contents of a counseling session. Any use or disclosure of these notes requires your separate written authorization, which cannot be combined with consent for other types of records. You can revoke that authorization at any time, except to the extent that I have already acted on it.

3. Marketing. I will not use or disclose your PHI for marketing purposes.

4. Sale of PHI. I will not sell your PHI.

5. All other uses. Uses and disclosures not described in this notice will be made only with your written authorization. You may revoke an authorization in writing at any time, except to the extent that I have already acted on it.

IV. Uses and disclosures that do not require your authorization

Subject to certain limits in the law, I can use and disclose your PHI without your authorization:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the requirements of that law.
2. For public health activities, including reporting suspected child, elder, or vulnerable 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. My preference is to obtain your authorization before doing so.
5. For law enforcement purposes, including reporting crimes occurring on my premises.
6. To coroners or medical examiners performing duties authorized by law.
7. For research purposes, such as comparing the outcomes of clients who received one form of treatment with those who received another for the same condition.
8. For 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 in or housed in correctional institutions.
9. For workers’ compensation purposes. My preference is to obtain your authorization, but I may provide PHI to comply with workers’ compensation laws.
10. For appointment reminders and information about services. I may use your PHI to remind you of an appointment, or to tell you about treatment alternatives or other services I offer.

V. Uses and disclosures where you have the opportunity to object

1. Family, friends, coaches, programs, and others. I will not share your PHI with family members, friends, coaches, teams, athletic programs, or anyone else involved in your care or in paying for it, including someone who pays for your sessions, without your written authorization. The one exception is an emergency in which you are unable to agree; in that case I will share only what the situation requires, and will tell you afterward.

2. Fundraising. I do not fundraise. If I ever intended to use or disclose records protected by 42 C.F.R. Part 2 for fundraising for my benefit, I would first give you a clear and conspicuous opportunity to opt out.

VI. Your rights regarding your PHI

1. The right to request limits on uses and disclosures. You may ask me not to use or disclose certain PHI for treatment, payment, or health care operations. I am not required to agree, and I may say no if I believe the restriction would affect your care.

2. The right to request restrictions for services paid in full out of pocket. You may request that PHI about a service you paid for in full out of pocket not be disclosed to a health plan for payment or health care operations. All services at this practice are private pay, and I do not bill health plans.

3. The right to choose how I contact you. You may ask me to contact you in a specific way (for example, a particular phone number or email address), or to send mail to a different address. I will agree to all reasonable requests.

4. The right to see and get copies of your PHI. Other than psychotherapy notes and SUD counseling notes, you have the right to an electronic or paper copy of your record and other information I have about you. I will provide a copy of your record, or a summary if you agree to receive one, within 30 days of receiving your written request. I may charge a reasonable, cost-based fee.

5. The right to a list of disclosures I have made. You may request a list of disclosures of your PHI made for purposes other than treatment, payment, or health care operations, or other than those you authorized. I will respond within 60 days. The list will cover the last six years unless you request a shorter period. The first list in any 12-month period is free; I may charge a reasonable, cost-based fee for additional requests in the same period. You may also request an accounting of disclosures of substance use disorder records protected under 42 C.F.R. Part 2.

6. The right to correct or update your PHI. If you believe there is a mistake in your PHI, or that important information is missing, you may ask me to correct or add to it. I may say no, but if I do, I will tell you why in writing within 60 days.

7. The right to be notified of a breach. You have the right to be notified if a breach of your unsecured PHI occurs.

8. The right to a paper or electronic copy of this notice. You may have a copy of this notice by email, and you may also request a paper copy at any time.

VII. Questions and complaints

If you have questions about this notice, or believe your privacy rights have been violated, contact me using the contact details at the top of this notice.

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue SW, Washington, D.C. 20201; by phone at 1-877-696-6775; or online at www.hhs.gov/ocr/complaints.

You will not be retaliated against in any way for filing a complaint.