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:
- Make sure that protected health information (“PHI”) that identifies you is kept private.
- Give you this notice of my legal duties and privacy practices with respect to PHI.
- Notify you following a breach of unsecured PHI and mitigate, to the extent practicable, any harmful effect caused by such breach.
- Follow the terms of the notice that is currently in effect.
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:
- Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your authorization unless the use or disclosure is:
a. For my use in treating you;
b. 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;
c. For my use in defending myself in legal proceedings instituted by you;
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA;
e. Required by law and the use or disclosure is limited to the requirements of such law;
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes;
g. Required by a coroner who is performing duties authorized by law; or
h. Required to help avert a serious threat to the health and safety of others.
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.
- Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
- Sale of PHI. As a psychotherapist, I will not sell your PHI.
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:
- Required by Law. I may use or disclose your PHI as required by state or federal law, where the use or disclosure complies with and is limited to the relevant requirements of such law.
- Public Health Activities. Examples of permitted uses and disclosures include reporting suspected child, elder, or dependent adult neglect or abuse, or preventing or reducing a serious threat to anyone’s health or safety.
- Health Oversight Activities. Examples of permitted uses and disclosures include audits and investigations.
- Judicial and Administrative Proceedings. Examples of permitted uses and disclosures include responding to a court or administrative order, discovery request, or subpoena. However, if permitted, I will make efforts to tell you about the request or order so that you may object or seek an order protecting the confidentiality of the information.
- Law Enforcement Purposes. Examples of permitted uses and disclosures include reporting crimes occurring on my premises.
- Information about Decedents. Examples of permitted uses and disclosures include helping coroners or medical examiners identify a deceased person or determine the cause of death.
- Research Purposes. Examples of permitted uses and disclosures include studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
- Specialized Government Functions. Examples of permitted uses and disclosures include 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 within or housed in correctional institutions.
- Workers’ Compensation Purposes. Although my preference is to obtain an authorization from you, I may provide your PHI to comply with workers’ compensation laws.
- Appointment Reminders and Health Related Benefits or Services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives or other health care services or benefits that I offer.
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:
- Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part.
III. YOUR RIGHTS
You have the following rights with respect to your PHI:
- The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to make certain uses or disclosures of PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
- The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
- The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
- The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.
- The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
- The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request. Regardless of whether you request such a list, I will keep a record of every disclosure including the date, the name of the recipient of the PHI, and a description of the contents of the disclosure.
- The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by email. And, even if you have agreed to receive this Notice via email, you also have the right to request a paper copy of it.
- The Right to Make a Complaint. 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, for example through their website. You will not be retaliated against for filing a complaint.
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.