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.
For further information about my privacy policies, please feel free to contact me.
I. MY PLEDGE REGARDING HEALTH INFORMATION
As the person responsible for making the privacy and security practices and procedures for my practice, I will make every effort to safeguard information regarding our work together in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Code of Federal Regulations (CFR) sections governing the privacy of health information, the Ethical Principles of Psychologists and Code of Conduct of the American Psychological Association, and any applicable state laws (such as the D.C. Mental Health Information Act of 1978 or the Virginia Patient Health Records Privacy Act of 1997).
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 I describe certain obligations I have regarding the use and disclosure of your health information.
I am required by law to:
I can change the terms of this Notice (for example to comply with new laws or regulations), and such changes will apply to all information I have about you. I will give you written notice, either through a physical document or email, if any such changes are made.
II. HOW I MAY USE AND DISCLOSE INFORMATION ABOUT YOU
In general, I may disclose confidential information with your consent unless prohibited by law, and I may disclose confidential information without your consent only as mandated by law, or where permitted by law for a valid purpose such as to (1) provide needed professional services; (2) obtain appropriate professional consultations; (3) protect you, me, or others from harm; or (4) obtain payment for services from you, in which instance disclosure is limited to the minimum that is necessary to achieve the purpose.
Below, I 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.
A. Treatment, payment, or health care operations:
Federal privacy regulations allow health care providers who have a direct treatment relationship with the patient to use or disclose the patient’s personal health information without the patient’s written authorization to carry out the health care provider’s treatment, payment, or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization.
For example, if I were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist me in the diagnosis and treatment of your mental health condition.
When consulting with colleagues, I will not disclose confidential information that could reasonably lead to your identification unless I have obtained your prior consent or the disclosure cannot be avoided, and I will disclose information only to the extent necessary to achieve the purposes of the consultation.
B. Certain uses and disclosures require your authorization:
Subject to certain limitations in the law, I can only use or disclose your PHI with your authorization for the following categories:
You may revoke an authorization to disclose psychotherapy notes, provided that the revocation is in writing, except to the extent that (1) I have acted in reliance on your prior authorization or (2) if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.
C. Certain uses and disclosures 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 categories:
D. Certain uses and disclosures require you to have the opportunity to object:
Subject to certain limitations in the law, I can only use or disclose your PHI for the following categories if you have the opportunity to object:
III. YOUR RIGHTS
You have the following rights with respect to your PHI:
EFFECTIVE DATE OF THIS NOTICE: This notice went into effect on May 3, 2021.
 You may request that I not disclose your mental health information to other health care providers in connection with the diagnosis, evaluation, treatment, case management, conduct of quality assessment and improvement activities, or rehabilitation of a health or mental disorder or disease when and to the extent necessary to facilitate the delivery of health or professional services to you.