Notice of Privacy Practices

I. My Pledge Regarding Health Information

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, which I need to provide you with quality care and to comply with certain legal requirements.

This notice applies to all records of your care generated by this mental health care practice. I am required by law to:

• Keep protected health information ("PHI") that identifies you private and secure.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice currently in effect.
• Notify you of any changes to this Notice — the updated Notice will be available upon request, in my office, and on this website.

II. How I May Use and Disclose Health Information About You

Federal privacy rules allow health care providers with a direct treatment relationship to use or disclose a patient's personal health information without written authorization to carry out treatment, payment, or health care operations. For example, if consulting with another licensed provider about your condition, I may use and disclose your personal health information to assist in diagnosis and treatment. Disclosures for treatment purposes are not limited to the minimum necessary standard, as providers need access to full records to provide quality care.

Lawsuits and Disputes

If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order, subpoena, or other lawful process — but only after efforts have been made to notify you about the request or to obtain a protective order.

III. Certain Uses and Disclosures Require Your Authorization

1. Psychotherapy Notes. Any use or disclosure of psychotherapy notes requires your written authorization, unless the use is for my own treatment of you, training or supervising practitioners, defending myself in legal proceedings you initiate, compliance oversight, or when required by law.
2. Marketing Purposes. I will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. I will not sell your PHI in the regular course of business.

IV. Certain Uses and Disclosures Do Not Require Your Authorization

Subject to certain limitations in the law, I may use and disclose your PHI without authorization for:

1. Uses required by state or federal law.
2. Public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing a serious threat to anyone's health or safety.
3. Health oversight activities, including audits and investigations.
4. Judicial and administrative proceedings (my preference is to obtain your authorization first).
5. Law enforcement purposes, including reporting crimes on my premises.
6. Coroners or medical examiners performing duties authorized by law.
7. Research purposes, including comparative mental health studies.
8. Specialized government functions (military, national security, correctional institutions).
9. Workers' compensation purposes (my preference is to obtain your authorization first).
10. Appointment reminders and information about treatment alternatives or health care services I offer.

V. Certain Uses and Disclosures Require You to Have the Opportunity to Object

I may provide your PHI to a family member, friend, or other person you indicate is involved in your care or payment for your care, unless you object in whole or in part. Consent may be obtained retroactively in emergency situations.

VI. Your Rights With Respect to Your PHI

1. Right to Request Limits. You may ask me not to use or disclose certain PHI for treatment, payment, or operations. I am not required to agree, and may decline if it would affect your health care.
2. Right to Request Restrictions for Out-of-Pocket Expenses. You may request restrictions on disclosures to health plans for items or services you paid for out-of-pocket in full.
3. Right to Choose How I Contact You. You may ask me to contact you in a specific way or at a different address. I will agree to all reasonable requests.
4. Right to See and Get Copies of Your PHI. You have the right to an electronic or paper copy of your medical record. I will provide a copy or summary within 30 days of your written request, and may charge a reasonable cost-based fee.
5. Right to Get a List of Disclosures. You may request a list of disclosures I have made for purposes other than treatment, payment, or operations, covering the last six years. I will respond within 60 days. The first request each year is free; additional requests may be charged a reasonable fee.
6. Right to Correct or Update Your PHI. You may request corrections or additions to your PHI. I may decline, but will provide a written reason within 60 days.
7. Right to a Copy of This Notice. You have the right to a paper or electronic copy of this Notice at any time.
8. Authorized Representatives. If you have given someone medical power of attorney or they are your legal guardian, they may exercise your rights on your behalf after I verify their authority.
9. Right to File a Complaint. You may complain if you feel I have violated your rights by contacting me, or by filing a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:
   200 Independence Avenue, S.W., Washington, D.C. 20201
   Phone: 1-877-696-6775
   Website: www.hhs.gov/ocr/privacy/hipaa/complaints/

I will not retaliate against you for filing a complaint.