THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT.

I am required by Federal and State law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices.

Use and Disclosure of Health Information

Unless you give me written authorization, I cannot use or disclose your health information for any reasons except those described below. If you give me an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.

Exceptions

1.      In the event of your incapacity or emergency circumstances, I will disclose only that health information which, in my professional judgment, is directly relevant to your care.

2.     I may use or disclose your health information when I am required to do so by law, for example, when ordered by a court with appropriate jurisdiction over the matter.

3.     I may disclose your health information to appropriate authorities if I have a reasonable belief that you are a possible victim of abuse, neglect, domestic violence, or other crimes. I may disclose your information to the extent necessary to avert a serious threat to your health or safety or to the health or safety of others.

4.     I may disclose to military authorities the health information of Armed Forces personnel under certain circumstances involving national security. I may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities.

5.     I may disclose health information to correctional institutions or law enforcement officials who have lawful jurisdiction over protected health information.

Client Rights

You have the right to inspect or obtain copies of your health information, except for therapist’s notes and certain other limited exceptions. You should make your request in writing to me. You may request that I provide copies in a format other than photocopies.

I will use the format you request unless I cannot practically do so. I will charge you a reasonable, cost-based fee for providing your health information in the chosen format. If you prefer, I will prepare a summary or an explanation of your health information, and will charge a reasonable fee for this service, based on the preparation time involved.

If access to your health information is denied, you or your personal representative will be provided with a written denial, setting forth the basis for the denial, a description of how you may appeal the decision and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services.

You have the right to receive a list of instances in which I have disclosed your health information. If you request this accounting more than once in a 12 month period, I may charge you a reasonable, cost-based fee for responding to these additional requests.

You have the right to request that I place additional restrictions on my use or disclosure of your health information. I am not required to agree to these additional restrictions, but if I do, I will abide by our agreement (except in an emergency).

You have the right to request that I communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing, and your request must specify the alternative means or location, while providing satisfactory explanation of how payments will be handled under these circumstances.

You have the right to request that I amend your health information. Your request must be in writing, and it must explain why the information should be amended. I may deny your request under certain circumstances. I have 60 days after the request is made to act on the request. A single 30 day extension is permissible if I am unable to comply with the deadline. If the request is denied in whole or part, I will provide you with a written denial and explanation. You or your personal representative may then submit a written statement disagreeing with the denial and have the statement included with any future disclosure of your protected health information.

Questions and Complaints

If you want more information about my privacy practices or have questions or concerns, please speak with me about this. If you are concerned that I may have violated your privacy rights or any other of the client rights described above, you may raise this with me directly. You may also summit a written complaint to the U.S. Department of Health and Human Services; I will provide you with the address for such complaint upon request. I support your right to privacy and will not retaliate in any way if you choose to file a complaint with me or with the U.S. Department of Health and Human Services.