This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
My Privacy Commitment to You
Your privacy is of the utmost importance to me. As a Licensed Marriage and Family Therapist I create and maintain treatment records that contain individually identifiable health information about you. The information I have about you will be held to the highest levels of confidentiality. Unless you give me permission in writing, I will only disclose your information when I am ethically and legally required to do so.
I am required by law to give you this notice of my privacy practices and maintain the privacy of your confidential information. This information and records I have about your psychotherapy, mental health status, and the care you receive at this office are referred to as “protected health information” or PHI. This document will tell you about the ways in which I may use and disclose your protected health information and describes your rights and my obligations regarding the use and disclosure of that information.
How I May Use and Disclose Protected Health Information About You
Ordinarily, everything that we discuss will be held in complete confidence by me. However, there are certain exceptions that are provided by law. If I ever need to break confidentiality in a way that would effect you in a significant manner, I will make every effort to discuss it with your beforehand. At my discretion I may use or disclose information about you without your permission, subject to all applicable legal requirements and limitations:
Supervision or Consultation: I periodically discuss cases with colleagues for the purposes of consultation. This is an established practice in the field of psychotherapy and is beneficial to your treatment. I make every effort to keep identifying information private and my colleagues are bound to the same standards of confidentiality as I am.
To Avert a Serious Threat to Health or Safety: I may use and disclose confidential information about you when necessary to prevent a serious threat to your health and safety or the health and safety of another person. I am required to disclose to the appropriate authorities knowledge of child abuse or abuse of the elderly.
Lawsuits and Disputes: If you are involved in a lawsuit or dispute, I may disclose information about you in response to a court or administrative order, subject to all legal requirements.
Required by Law: I will disclose health information about you when required by federal, state, or local law.
The above list is not an exhaustive list, but informs you of most circumstances when disclosures without your written authorization may be made. Other uses and disclosures will generally, but not always, be made only with your written authorization, even though federal privacy regulations or state law may allow additional uses or disclosures without your written authorization. You may revoke your written authorization at any time, provided that the revocation is in writing and except to the extent that I have already taken action based on your written authorization.
Your Privacy Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you.
Right to Inspect and Copy: You have the right to inspect and copy protected health information about you by making a specific request to do so in writing. This right to inspect and copy is not absolute – in other words, I am permitted to deny access for specified reasons. For instance, you do not have this right of access with respect to my psychotherapy notes. The term “psychotherapy notes” refers to notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s mental health record. The term excludes counseling session start and stop times, the modalities and frequencies of treatment furnished, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
Right to Amend: You have the right to amend information in my records by making a request to do so in a writing that provides a reason to support the requested amendment. This right to amend is not absolute – in other words, I am permitted to deny the requested amendment for specified reasons. You also have the right, subject to limitations, to provide me with a written addendum with respect to any item or statement in your records that you believe to be incorrect or incomplete and to have the addendum become a part of your record.
Right to an Accounting of Disclosures: You have the right to receive an accounting from me of the disclosures of protected health information made by me in the six years prior to the date on which the accounting is requested. As with other rights, this right is not absolute. In other words, I am permitted to deny the request for specified reasons. For instance, I do not have to account for disclosures of protected health information that are made with your written authorization, since you have a right to receive a copy of any such authorization you might sign.
Right to a Paper Copy of this Notice: You have the right to obtain a paper copy of this notice from me upon request at any time. Even if you have agreed to receive it electronically you are still entitled to a paper copy.
Right to Restrict Disclosures to a Health Plan: You have the right to restrict certain disclosures of your protected health information to a health plan for services that have been paid for in full out-of-pocket by you or by another person on your behalf. Since I do not have any contracts or formal relationships with any insurance companies you will be dealing with your insurance company and I will not disclose any information to them directly.
Right to Choose Someone to Act for You: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. I will make sure the person has this authority and can act for you before I take any action.
Right to File a Complaint if You Feel Your Rights Are Violated: Because I am the Contact Person for my practice, you may complain to me if you believe your privacy rights may have been violated. You may file a complaint with me in person, via phone, or in writing. I always encourage you to discuss with me in person any complaints you have with the treatment I am providing. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. I will not retaliate against you in any way for filing a complaint with me or with the Secretary.
I am required by law to maintain the privacy and confidentiality of your protected health information. This notice is intended to let you know of my legal duties, your rights, and my privacy practices with respect to such information.
As the Privacy Officer of this practice, I have a duty to develop, implement and adopt clear privacy policies and procedures for my practice and I have done so. I am the individual who is responsible for assuring that these privacy policies and procedures are followed not only by me, but by any employees that work for me or that may work for me in the future. I have trained or will train any employees that may work for me so that they understand my privacy policies and procedures.
In general, client records and information about clients are treated as confidential in my practice and are released to no one without the written authorization of the client except as indicated in this notice or as may be otherwise permitted by law.
Electronic Records Disclosure
I keep and store records for each client electronically using a laptop computer in my office. I employ firewalls, antivirus software, passwords, and disk encryption to protect the computer from unauthorized access and thus to protect the records from unauthorized access. Your records are kept for a minimum of six years from the date of termination of therapy.
To help prevent the loss or damage of records I keep backups using encrypted storage devices. Backups are made daily and are kept safely in my office.
While I use security measures to protect these electronic records, their security cannot be guaranteed. I make every effort to secure your confidential records. However, I will notify you in the event of a breach of your unsecured protected health information as required by law.
Changes to the Terms of this Notice
I can change the terms of this notice and the changes will apply to all information we have about you. The new notice will be available upon request, in my office, and on my web site.
I will never market any products or services to you or sell your protected health information to any third party for marketing purposes. The confidentiality of your information is a cornerstone of effective counseling and my intention is to keep what we say and do together confidential.
If you need or desire further information related to this Notice or its contents, or if you have any questions about this Notice or its contents, please feel free to contact me. As the Privacy Officer for this practice, I will do my best to answer your questions and to provide you with additional information.
This notice was last updated on September 16, 2023.
No Surprises Act / Good Faith Estimate (GFE) Disclosure
You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 368-1019.
I am currently not contracted with any insurance plans. Be aware that some or all of the amounts paid might not count toward your insurance deductible or out-of-pocket limit. Since the length of therapy varies, estimates do not show the per-session costs for one to 52 sessions, as the estimate is valid for 12 months. I always provide advance notice of fee adjustments.