“If you deliberately plan on being less than you are capable of being, then I warn you that you’ll be unhappy for the rest of your life.”
— Abraham Maslow
THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
I am required by law to maintain the privacy of your protected health information (PHI) and to provide you with notice of your privacy rights and my legal duties and privacy practices with respect to your PHI. I am required to abide by the terms of this notice with respect to your PHI but reserve the right to change the terms of this notice and make the new notice provisions effective for all PHI that I maintain. I will provide you with a copy of the revised notice sent by regular mail to the last address you have provided to me for this communication purpose.
Each time you visit a hospital, physician, mental health professional or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms; examination and test results; diagnoses; treatment; in the case of a mental health professional, psychotherapy notes; and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as:
Understanding what is in your record and how your health information is used helps you to:
Although your health record is the physical property of my practice, the facility that compiled it, the information belongs to you. You have the following privacy rights:
I am not required to agree to be bound by any restrictions that you request but am bound by each restriction that I do agree to.
You may request copies of your PHI by providing me with a written request for such copies. I will provide you with copies within ten (10) business days of your request at my office. You will be charged $.25 for each page copied, and you will be expected to pay for the copies at the time you pick them up.
I am required to act on your request to amend your PHI within sixty (60) days, but this deadline may be extended for another thirty (30) days upon written notice to you. If I deny your requested amendment, I will provide you with written notice of my decision and the basis for my decision. You will then have the right to submit a written statement disagreeing with my decision, which will be maintained with your PHI. If you do not wish to submit a statement of disagreement, you may request that I provide your request for amendment and my denial with any future disclosures of your PHI.
I am required to act on your request for an accounting within sixty (60) days, but this deadline may be extended for another thirty (30) days upon written notice to you of the reason for the delay and the date by which I will provide the accounting. You are entitled to one (1) accounting in any twelve (12) month period free of charge. For any subsequent request in a twelve (12) month period you will be charged $.25 for each page copied, and you will be expected to pay for the copies at the time you pick them up.
Your written authorization is required before I can use or disclose my psychotherapy notes, which are defined as my notes documenting or analyzing the contents of our conversations during our counseling sessions and that are separated from the rest of your clinical file. Psychotherapy notes do not include medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
It is my policy to protect the confidentiality of your PHI to the best of my ability and to the extent permitted by law. There are times, however, when use or disclosure of your PHI including, psychotherapy notes, is permitted or mandated by law even without your authorization.
Situations in which I am not required to obtain your consent or authorization for use or disclosure of your PHI psychotherapy notes include the following circumstances:
For example: Information obtained by me will be recorded in your record and used to determine the course of treatment that should work best for you. I will document in your record our work together and, when appropriate, I will provide a subsequent counselor or healthcare provider with copies of various reports that should assist him or her in treating you once we have terminated our therapeutic relationship.
For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
To a public health authority or other government authority authorized by law to receive reports of child abuse or neglect.
If I reasonably believe an adult individual to be the victim of abuse, neglect, or domestic violence, I may report to a governmental authority, including a social services agency authorized by law to receive such reports to the extent the disclosure is required by or authorized by law or you agree to the disclosure and I believe in the exercise of my professional judgement disclosure is necessary to prevent serious harm to you or other potential victims. If I make such a report, I am obligated to inform you unless I believe informing you will place the individual at risk of serious injury.
In the course of any judicial or administrative proceeding in response to:
- an order of a court or administrative tribunal so long as only the PHI expressly authorized by such order is disclosed, or
- a subpoena, discovery request, or other lawful process, that is not accompanied by an order of a court or administrative tribunal so long as reasonable efforts are made to give you notice that your PHI has been requested or reasonable efforts are made to secure a qualified protective order, by the person requesting the PHI.
In child custody cases and other legal proceedings in which your mental health or condition is in issue.
In connection with a suit to collect fees for my services.
In compliance with a court order or court ordered warrant, or a subpoena or summons issued by a judicial officer, a grand jury subpoena or summons, a civil or an authorized investigative demand or similar process authorized by law provided that the information sought is relevant and material to a legitimate law enforcement inquiry, the request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought and de-identified information could not reasonably be used.
To a health oversight agency for oversight activities authorized by law as they may relate to me (i.e. audits; civil, criminal or administrative investigations, inspections, licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions.)
To a public health authority that is authorized by law to collect or receive such information for the purposes of preventing or controlling a disease, injury, or disability, including, but not limited to, the reporting of disease, injury, vital events such as birth, death, and the conduct of public surveillance, public health investigations, and public health interventions.
I may contact you with appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.
Contact with my office via email, telephone, or initial consultation does not constitute a therapeutic relationship. Until we have both agreed to proceed with counseling, and have both signed an Informed Consent for Treatment, you are not a client with me. If you are experiencing a mental health crisis or you are in imminent danger of harming yourself or someone else, call 911 and wait for instruction, or proceed immediately to a nearby emergency room.
If you have any questions or want additional information, you should bring these questions or this want to my attention at the first opportunity. I am the designated Privacy Officer for my practice and will be glad to respond to your questions or request for information.