Reclaim Your
Innermost
Wellbeing

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. 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.

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 health information.
• Follow the terms of the notice that is currently in effect.

I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

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

For Treatment, Payment, or Health Care Operations: Federal privacy rules allow health care providers who have a direct treatment relationship with the patient/client to use or disclose the patient/client's personal health information without written authorization, to carry out treatment, payment or health care operations. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information to assist in diagnosis and treatment of your mental health condition.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order, subpoena, discovery request, or other lawful process, but only if efforts have been made to tell you about the request or to obtain a protective order.

III. Certain Uses and Disclosures Require Your Authorization

Psychotherapy Notes. I do keep psychotherapy notes as defined in 45 CFR § 164.501. Any use or disclosure of such notes requires your authorization unless required by law, for my own treatment of you, for training or supervision, for legal defense, or to avert a serious threat to health and safety.

Marketing & Sale of PHI. As a psychotherapist, I will not use or disclose your PHI for marketing purposes, nor will I sell your PHI in the regular course of my business.

IV. 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 reasons:

• When required by state or federal law
• For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing a serious threat to anyone's health or safety
• For health oversight activities, including audits and investigations
• For judicial and administrative proceedings
• For law enforcement purposes
• To coroners or medical examiners performing duties authorized by law
• For research purposes
• For workers' compensation purposes
• For appointment reminders and health-related benefits or services

V. 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.

VI. Your Rights With Respect to Your PHI

• Right to Request Limits on uses and disclosures of your PHI.
• Right to Request Restrictions for out-of-pocket expenses paid in full.
• Right to Choose How I Send PHI to you (by phone, mail, etc.).
• Right to See and Get Copies of your PHI within 30 days of written request.
• Right to Get a List of Disclosures I have made within the last six years.
• Right to Correct or Update your PHI if you believe there is a mistake or omission.
• Right to a Paper or Electronic Copy of this Notice at any time.