Notice of Privacy Practices

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Privacy is a very important concern for all those who come to this office. It is also complicated because of the many federal and state laws and professional ethics guidelines. Because the rules are so complicated, some parts of this Notice are quite detailed and hard to understand. If you have any questions I will be happy to further explain these procedures and your rights.


  1. Introduction
  2. What is Meant by Your Medical Information
  3. Privacy and the Laws about Privacy
  4. How Your PHI Can be Used and Shared
  5. 4A. Uses and Disclosures With Your Consent
  6. 4A1. Basic Uses and Disclosures – For Treatment, Payment, or Healthcare Operations
  7. 4A2. Other Uses and Disclosures in Healthcare
  8. 4B. Uses and Disclosures that Require your Authorization
  9. 4C. Uses and Disclosures that Do Not Require your Consent or Authorization
  10. 4D. Uses and Disclosures Where You Have an Opportunity to Object
  11. 4E. Accounting for Disclosures I Have Made
  12. What To Do If You Have Questions or Problems


This Notice will tell you how I handle information about you. It tells how I use this information here in this office, how I share it with other professionals and organizations, and how you can access it. I want you to know all of this so that you can make the best decisions for yourself and your family. I am also required to tell you about this because of the privacy regulations of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Because this law and the laws of this state are very complicated and I don’t want to make you read a lot that may not apply to you, I have simplified some parts. If you have any questions or want to know more about anything in this Notice, please ask me for more explanation or more details.


Each time you visit me or any doctor’s office, clinic, or any other healthcare provider, information is collected about you and your physical and mental health. It may be information about your past, present or future health or conditions, or the treatment or other services you got from me or from others, or about payment for healthcare. In the law, the information I collect from you is called Protected Health Information (PHI). This information goes into your healthcare record at my office.

In my office, your PHI is likely to include the following kinds of information (these are just examples; there may be other kinds of information that go into your healthcare record also):

  • Your history – as a child, in school, at work, in your relationships
  • Reasons you came for treatment – your problems, complaints, symptoms, needs, goals
  • Diagnoses – the medical terms for your problems or symptoms
  • Treatment plan – a list of the treatments and any other services which I think will be
  • best to help you
  • Progress notes – the notes I make each time you come in about how you are doing,
  • what I notice about you, and what you tell me
  • Records I get from others who treated or evaluated you
  • Information about medications you took or are taking
  • Legal matters
  • Billing and insurance information
  • I use this information for many purposes. For example, I may use it:
  • To plan your care and treatment
  • To decide how well my treatments are working for you
  • When I talk with other healthcare professionals who are also treating you, such as your
  • family doctor or the professional who referred you to me
  • To show that you actually received the services from me which I billed to you or to your
  • health insurance company
  • For teaching and training other healthcare professionals
  • For medical or psychological research
  • For public health officials trying to improve healthcare in this area of the country
  • To improve the way I do my job by measuring the results of our work

When you understand what is in your record and what it is used for, you can make better decisions about to whom, when, and why the information is released.

Although your health record is the physical property of the healthcare practitioner or facility that collected it, the information belongs to you. You can inspect, read, or review it. If you want a copy, I can make one for you but I may charge you for the costs of copying (and mailing if you want it mailed to you). In some very unusual situations you cannot see all of what is in your records. If you find anything in your records that you think is incorrect or believe that something important is missing, you can ask me to amend (add information to) your record, although in some rare situations I don’t have to agree to do that. If you want, I can explain more about this.


The HIPAA law requires me to keep your PHI private and to give you this Notice of my legal duties and my privacy practices which is called the Notice of Privacy Practices (NPP). I will obey the rules of this NPP as long as it is in effect, but if I change it, the rules of the new NPP will apply to all the PHI I keep. If I change the NPP, I will post the new one in my office where everyone can see. You or anyone else can also get a copy from me at any time and it will be posted on my website ( as well.


When your information is read by me and used to make decisions about your care, in the law that is called “use.” If the information is shared with or sent to others outside this office, in the law that is called “disclosure.” Except in some special circumstances, when I use your PHI here or disclose it to others, I share only the minimum necessary PHI needed for the purpose. The law gives you rights to know about your PHI, how it is used and to have a say in how it is disclosed (shared) and so I will tell you more about what I do with your information.

I use and disclose PHI for several reasons. Mainly, I will use and disclose it for routine purposes and I will explain more about these below. For other uses, I must tell you about them and have a written Authorization from you unless the law lets or requires me to make the use or disclosure without your authorization. However, the law also says that I am allowed to make some uses and disclosures without your consent or authorization.


After you have read this Notice you will be asked to sign a separate Consent Form to allow me to use and share your PHI. In almost all cases, I intend to use your PHI here or share your PHI with other people or organizations to provide treatment to you, arrange for payment for my services, or some other business functions called healthcare operations. Together these routine purposes are called TPO and the Consent Form allows me to use and disclose your PHI for TPO. Re-read that last sentence until it is clear because it is very important.


I need information about you and your condition to provide care to you. You have to agree to let me collect the information and to use it and share it as necessary to care for you properly. Therefore you must sign the Consent Form before we begin to treat you because if you do not agree and consent I cannot treat you.

When you come to see me, I will collect information about you and all of it may go into your healthcare records here. Generally, I may use or disclose your PHI for three purposes: treatment, obtaining payment, and what are called healthcare operations. I will explain what these are all about.

For Treatment

I use your PHI to provide you with psychological treatment or services. These might include individual, family, or group therapy, psychological, educational, or vocational testing, treatment planning, and measuring the effects of my services.

I may share or disclose your PHI to others who provide treatment to you. I am likely to share your information with your personal physician. If you are being treated by a team, I can share some of your PHI with them so that the services you receive will be coordinated. They will also enter their findings, the actions they took, and their plans into your record so we all can decide what treatments work best for you and make up a Treatment Plan. I may refer you to other professionals or consultants for services I cannot offer such as special testing or treatments. When I do this I need to tell them some things about you and your conditions. I will get back their findings and opinions and those will go into your records here. If you receive treatment in the future from other professionals I can also share your PHI with them. These are some examples so that you can see how I use and disclose your PHI for treatment.

For Payment

I and my billing agent may use your information to bill you, your insurance, or others to be paid for the treatment I provide to you. We may contact your insurance company to check on exactly what your insurance covers. We may have to tell them about your diagnoses, what treatments you have received, and what I expect as I treat you. We will need to tell them about when we met, your progress, and other similar things.

For Healthcare Operations

There are some other ways I may use or disclose your PHI which are called healthcare operations. For example, I may use your PHI to see where I can make improvements in the care and services I provide. I may be required to supply some information to some government health agencies so they can study disorders and treatment and make plans for services that are needed. If I do, your name and identity will be removed from what I send.


Appointment Reminders

I may use and disclose PHI to reschedule or remind you of appointments for treatment or other care. If you want me to call or write to you only at your home or your work or prefer some other way that I contact you, I can usually arrange that if you tell me.

Treatment Alternatives

I may use and disclose your PHI to tell you about or recommend possible treatments or alternatives that may be of interest to you.

Other Benefits and Services

I may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.


I may use or share your information to do research to improve treatment. For example, the research might compare two treatments for the same disorder to see which works better or faster or costs less. In all cases your name, address and other information that reveals who you are will be removed from the information given to researchers. If they need to know who you are I will discuss the research project with you and you will have to sign a special Authorization Form before any information is shared.

Business Associates

There are some jobs I hire other businesses to do for me. In the law, they are called my Business Associates. For example, I use a billing agent who figures out, prints, and mails my bills. Business associates need to receive some of your PHI to do their jobs properly. To protect your privacy they have agreed in their contract with me to safeguard your information.

If I want to use your information for any purpose besides the TPO or those I described above, I need your permission on an Authorization Form. I don’t expect to need this very often.

If you do authorize me to use or disclose your PHI, you can revoke (cancel) that permission, in writing, at any time. After that time I will not use or disclose your information for the purposes that we agreed to. Of course, I cannot take back any information I had already disclosed with your permission or that I had used in my office.


The laws let me use and disclose some of your PHI without your consent or authorization in some cases. Here are some examples of when I might have to share your information:

As Required By Law to Prevent a Serious Threat to Health or Safety of You or Someone Else

  • If you are clearly dangerous to yourself, I may take steps to seek involuntary hospitalization and may also contact members of your family and/or the emergency contact you gave me.

  • If you threaten to kill or seriously hurt someone and I believe you may carry out your threat, or if I believe you will attempt to kill or seriously hurt someone, I may tell any reasonably identified potential victim, notify the police, and/or arrange for you to be hospitalized.

  • If I have reasonable cause to believe that serious physical or emotional injury resulting from abuse or neglect has been inflicted on a child, elderly person, or disabled person, I am mandated by law to call the appropriate government agency.

As Required by Law to Comply with Legal Proceedings

If you are involved in a lawsuit or legal proceeding and I receive a subpoena, discovery request, or other lawful process I may have to release some of your PHI. I will only do so after trying to tell you about the request, consulting your lawyer, or trying to get a court order to protect the information they requested. The following are some possible examples:

  • If a court orders me to produce evidence in a child custody or adoption case or need-to- hospitalize case
  • In court proceedings involving the care and protection of children
  • In a legal proceeding where you, your legal representative, or (after your death) a
  • beneficiary of your estate introduces your mental or emotional condition
  • If you bring a legal action against me and disclosure is necessary or relevant to a defense
  • If a court orders access to your records in a sexual assault or other criminal case

 For Law Enforcement Purposes

I may release some of your PHI if asked to do so by a law enforcement official to investigate a crime or criminal.

For Public Health Activities

I might disclose some of your PHI to agencies which investigate diseases or injuries.

For Specific Government Functions

I may disclose PHI of military personnel and veterans to government benefit programs relating to eligibility and enrollment, to Workers’ Compensation programs, to correctional facilities if you are an inmate, and for national security reasons.

When Audited For HIPAA Compliance

I have to release some information to the government agencies which check on me to see that I am obeying the privacy laws.


I can share some of your PHI about you with your family or close others. I will only share information with those involved in your care and anyone else you choose such as close friends or clergy. I will ask you about who you want me to tell what information about your condition or treatment. You can tell me what you want and I will honor your wishes as long as it is not against the law.

If it is an emergency – so I cannot ask if you disagree – I can share information if I believe that it is what you would have wanted and if I believe it will help you if I do share it. If I do share information in an emergency, I will tell you as soon as I can. If you don’t approve, I will stop, as long as it is not against the law.


When I disclose your PHI I keep some records about to whom I sent it, when I sent it, and what I sent. You can get an accounting (a list) of many of these disclosures.


If you need more information or have questions about the privacy practices described above, please speak to me. If you have a problem with how your PHI has been handled or if you believe your privacy rights have been violated, contact me. You have the right to file a complaint with me and with the Secretary of the Federal Department of Health and Human Services. I promise that I will not in any way limit your care here or take any actions against you if you complain.

The effective date of this Notice is April 14, 2003.