NOTICE OF PRIVACY PRACTICES
In 1996, Congress passed the Health Information Portability and Accountability Act (HIPAA) to better protect the confidentiality of your medical and mental health information. This notice describes how psychological information about you may be used, disclosed, and how you can get access to this information. Please read this notice carefully. The privacy of your medical health information is important to me.
LEGAL DUTY: I am legally obligated by federal and state law to maintain the privacy of your medical and mental health information. I am also required to give you this notice which outlines my privacy policies, outlines legal duties, and your rights concerning protected health information.
We are required to follow the privacy practices that are in this notice since HIPAA took effect on April 1, 2003. The terms in this notice will remain in effect until we replace it.
We reserve the right to change our privacy policies and the terms of the notice at any time, as permitted by law. Any changes to our privacy practices apply to all protected health information that we maintain, which includes information gathered or created prior to changes to the practices being made. Any significant change in our privacy practices will be published in a new notice, and will be available to you
as soon as the changes are implemented.
USES AND DISCLOSURES OF MENTAL HEALTH INFORMATION: I may use and disclose mental health information about your treatment, payment, and mental health healthcare business operations.
TREATMENT: I may use and disclose your mental health information to a physician, psychologist, psychiatrist, or other health care professional providing treatment to you.
PAYMENT: I may use or disclose your health information to obtain payment for services I provide to you.
YOUR AUTHORIZATION: In addition to my use of your mental health information for treatment, payment, or mental health business operations, you may give me written authorization to use your mental health information or to disclose it to anyone for any purpose. Unless you provide written authorization, we cannot use or disclose your mental health information for any reason, except for those described in this notice. If you give us a signed authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization which was in
effect.
TO YOUR FAMILY AND FRIENDS: I must disclose your mental health information to you as described in the patients rights section of this notice. I may disclose your mental health information to a family member, friend, or other person to the extent necessary to help your mental health care or with payment for services rendered, but only if you agree that we may do so with your signed authorization.
PERSONS INVOLVED IN YOUR CARE: I may use or disclose mental health information to notify or assist in the notification of a family member, your personal representative or other person(s) responsible for your care, your location, your general condition, or death. If you are present, prior to use
or disclosure of your health information, I will provide you with a mental health information based on a determination using my professional judgment, disclosing only mental health information that is directly relevant to the requesting individual’s involvement in your mental health care.
PLEASE RETAIN THIS FOR YOUR RECORDS