This notice describes how mental health information may be used and disclosed, and how you can gain access to this information. The Health Insurance Portability and Accountability Act (HIPAA) requires that I provide you with this Privacy Notice and that I obtain your signature acknowledging that you have received this information.

Confidentiality and Disclosure of Information:  In most situations, communications between therapist and client are confidential and may not be released without your written authorization. I will obtain authorization from you before using or disclosing any Protected Health Information.Written authorization for disclosure of confidential information may be revoked in writing. Parents of clients under 18 years of age are allowed to have access to information about their child’s treatment. Non-custodial parents also maintain this right. However, since the child’s privacy is critical to progress in psychotherapy, I may request that parents consent to give up their access to this information. Parents would be informed if their child demonstrates an imminent risk for self-harm or harm to others, or demonstrates a serious substance abuse problem.

There are exceptions to confidentiality, which require disclosure of information about you without your consent or authorization. These exceptions include situations involving dangerousness to yourself or others, if mistreatment of a minor or elder is suspected, if there is suspicion of sexual abuse, or if you are an impaired driver. Under these circumstances, relevant authorities, other treatment providers or family members may be contacted to facilitate necessary interventions. Other exceptions include court subpoenas of your clinical record, disclosures required by health insurers to pay your fee, or information required by legal or collection agencies to collect overdue fees. Further exceptions include narrowly defined disclosures to law enforcement agencies, health oversight agencies, a coroner or medical examiner for public health purposes relating to disease or FDA regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

Professional Records:  Based on HIPAA standards, information about you may be kept in two separate records. Protected Health Information is kept in your Clinical Record, and may include reasons for seeking treatment, problem description, medical, social and family history, diagnosis, prognosis and treatment goals, test results or past treatment records, billing and insurance information, a general description of what is discussed in sessions, and your progress in therapy. You also have the right to request to have a copy of your file made available to any other health care provider at your written request. You have a right to examine or copy your Clinical Record and amend such information. You also have a right to receive a copy of your Protected Health Information in an electronic format or (through your written authorization) designate a third party who may receive such information. Because these are professional records, they may be misinterpreted an/or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I deny your request to amend your records, you have a right to appeal this decision. An additional record of Psychotherapy Notes also may be kept in a separate file. These notes may include a more detailed description of your sessions, and any sensitive information about you or your family not required to be in your Clinical Record. These Psychotherapy Notes are not available to you, and cannot be released to anyone, including insurance companies, without your signed authorization. 

Patient Rights:  It is legally mandated that I maintain the privacy of your Protected Health Information and that I abide by the terms of this Notice. In addition to your right to review and amend your Clinical Record, you may request restrictions on what information from your Clinical Record is disclosed to others, determine the location to which disclosures are sent, request an accounting of unauthorized disclosures conducted under rare legal circumstances, request reasonable accommodations in standard practices (such as what phone messages can be left and where billing statements may be sent) and have a right to a copy of this Notice. You have the right to restrict certain disclosures of Protected Health Information to your health insurance company if you pay out-of -pocket in full for services. Other uses and disclosures not described in the notice will be made only with your written authorization. You must sign an authorization form for releases that are not mentioned in the Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired driving, etc.). Disclosures after the termination of psychotherapy that you do not authorize occur only under rare legal circumstances or to facilitate payment from insurers.

For a six-year period from the date this notice is signed, you have the right to receive an accounting of any disclosures made from your record. You have a right to be notified if there is a breach (a use or disclosure of your unsecured Protected Health Information in violation of the HIPAA Privacy Rule) that information was not encrypted to government standards, and my risk assessment fails to determine that there is a low probability that your Protected Health Information has been compromised. If there is any breach, I will notify you, the Department of Health and Human Services, and I will also reassess my privacy and security practices to determine what changes should be made to prevent the reoccurrence of such a breach.Please direct any complaints you have about my compliance with this Privacy Notice directly to me, or to the U.S. Department of Health and Human Services.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE PRIVACY NOTICE AND AGREE TO ITS TERMS.

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