PROTECTING YOUR PRIVACY

THIS NOTICE DESCRIBES HOW THE INFORMATION YOU SHARE MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. IT TAKES EFFECT 4/11/2008, AND REMAINS IN EFFECT UNTIL i REPLACE IT.

1. MY PLEDGE REGARDING MEDICAL AND MENTAL HEALTH INFORMATION: The privacy of your medical and mental health information is important to me. I understand that this information is personal, and I am committed to protecting it. I create a record of care you receive at my office. We need this record to provide you with quality service, and to comply with certain legal requirements. This notice will tell you about the ways I may use and share information about you, such as with your insurance company, always with your your expressed permission. It also describes your rights and certain duties I have regarding the use and disclosure of any information I receive from you.

2. MY LEGAL DUTY - Law requires me to:

  • Keep your medical/mental health information private.
  • Give you this notice describing my legal duties, privacy practices, and your rights regarding this information
  • Follow the terms of this notice, now in effect.

I have the right to:

  • Change my privacy practices and the terms of this notice at any time, provided the changes are permitted by law.
  • Apply changes in my privacy practices to all medical and mental health information that I keep, including informatio created or received before the  changes were made.

Notice regarding change to Privacy Practices: Before making any changes to my privacy practices, I will change this notice and make the new notice available upon request.

3. USE AND DISCLOSURE OF YOUR MEDICAL AND MENTAL HEALTH INFORMATION

The following section describes different ways I may use and disclose medical information. Not every possible use or disclosure has been listed. However, I have listed all the different ways I am permitted to use and disclose this information. I will not use or disclose information about you for any purpose, including those listed below without your specific written authorization. You may revoke any specific written authorization you provide at any time by writing to me.

For treatment: I may use medical/mental health information about you to provide you with psychotherapy treatment and services. I may disclose this information about you to your other healthcare providers to assist them in treating you.

For Payment: I may use and disclose your medical and mental health information in order to receive insurance reimbursement.

Suspected victims of abuse, neglect or domestic violence: If I reasonably believe you are a possible victim of abuse, neglect or domestic violence, or the possible victim of other crimes, I may disclose information about you to appropriate authorities. I may share medical and mental health information if it seems necessary to prevent a serious threat to your health or the safety of others. I may share such information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime, or who has escaped legal custody.

Workers Compensation: I may disclose health/mental health information when authorized and necessary to comply with laws related to workers compensation or other similar programs.

Health Oversight Activities: I may disclose medical/health information to an agency providing oversight for oversight activities authorized by law, including audits, civil, administrative or criminal investigation or proceedings, inspections, licensure or disciplinary actions or other authorized activities.

Law Enforcement: Under certain circumstances, I may disclose health/mental health information to law enforcement officials. These circumstances include reporting required by certain laws (such as reporting suspected child abuse), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on my premises and crimes in emergencies.

4. YOUR INDIVIDUAL RIGHTS - You have a right to:

  • Copies of your records. If, in my opinion, accessing your actual records will be deleterious to your condition, I will make a synopsis of the records available to you. Please make your request in writing. If the record is lengthy, I reserve the right to charge a reasonable fee for copying and postage, if you want it mailed.
  • Receive a list of any and all times I shared your medical or mental health information for any purpose, including treatment, insurance reimbursement and case consultation.
  • Request that we place additional restrictions on my use or disclosure of your medical or mental health information.
  • Request that I communicate with you about your medical and mental health information by different means or to different locations.
  •  Request that I change your medical or mental health information. You may request in writing that these changes be communicated to others, and that I include the changes in any future sharing of this information. I may deny the request for change if I did not create the information, or for certain other reasons. If I do, I will furnish you with a written explanation. You may respond with a statement of disagreement that will be added to the information you want changed.
  •  You have the right to a paper copy of this notice.

5. QUESTIONS AND COMPLAINTS 6. ADDITIONAL USES AND DISCLOSURES

If you have any questions about this notice, or if you think I have violated your privacy rights, please contact me. You may also submit a complaint to The U.S. Department of Health and Human Services.

I will not retaliate in any way if you choose to file a complaint.

6. ADDITIONAL USES AND DISCLOSURES

Notification of other if you are at risk: If, for your safety, I have to notify or help notify a family member, your personal representative or another person responsible for your care of your condition. I will get permission from you beforehand, if possible. If you are not able to give or refuse permission, I will share only what is directly necessary for your healthcare, according to my professional judgement.

Disaster Relief: In case of disaster, I may be asked to release medical/mental health information to a public or private organization or person who can legally assist you.

Court Orders and Judicial and Administrative Procedures: I may disclose medical/mental health information in response to a court order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant or grand jury subpoena, I may share your medical/mental health information with law enforcement officials. I may share limited information with a law enforcement official concerning the medical/mental health information of a suspect, fugitive, material witness, crime victim or missing person. I may share medical/mental health information of an inmate or other person in lawful custody with a law enforcement official or correctional facility under certain circumstances.

Public Health Activities: As required by law, I may disclose your medical/mental health information to public health or legal authorities charged with preventing or controlling disease, injury, disability, including child abuse or neglect. I may also, when authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.