This notice describes how your mental health information may be used and disclosed, and how you can access this information. Please review it carefully.


I understand that your mental health care information is personal. I am committed to protecting your mental health information. In compliance with legal requirements and the prescribed standards of care with the mental health field, I am required to create a record of the care and services you receive from me. This notice will tell you about the ways in which I may use and disclose those records, and applies to all of the records I keep under your name. This notice further provides a description of your rights to the health information I keep about you, and describes certain obligations I have regarding the use and disclosure of your mental health information. Namely, I am required by law to:

  • Make sure that your PROTECTED HEALTH INFORMATION (PHI) is kept private.

  • Give you this notice of my legal duties and privacy practices with respect to mental health information.

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

  • I may 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.



For Treatment.  Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members.  I may disclose PHI to any other consultant only with your authorization.


For Payment.  I may use and disclose PHI so that I can receive payment for the treatment services provided to you.  This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.  If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection. 


For Health Care Operations.  I may use or disclose, as needed, your PHI in order to support my business activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided I have a written contract with the business that requires it to safeguard the privacy of your PHI.


Required by Law.  Under the law, I must make disclosures of your PHI to you upon your request.  In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.


Without Authorization.  Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization.  Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of situations.  As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy disclosures without an authorization.  The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.


Child Abuse or Neglect. I may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.


Judicial and Administrative Proceedings.  I may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.


Deceased Patients. I may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin.  PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.


Medical Emergencies. I may use or disclosure your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm.  I will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.


Family Involvement in Care. I may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.


Health Oversight. If required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.  Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.


Law Enforcement. I may disclose PHI to the law enforcement official required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises. 


Specialized Government Functions. I may review requests from U.S. Military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.


Public Health. If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, or to a government agency that is collaborating with that public health authority.


Public Safety. I may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.


Research. PHI may be disclosed after a special approval process or with your authorization.


Fundraising. I may send you fundraising communications at one time or another.  You have the right to opt out of such fundraising communications with each solicitation you receive.


Verbal Permission. I may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.


With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization.  The following uses and disclosures will be made only with your written authorization: (1) most uses and disclosures of psychotherapy notes which are separated from the rest of you medical record; (2) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (3) disclosures that constitute a sale of PHI; and (4) other uses and disclosures not described in the Notice of Privacy Practices.


  1. Regarding psychotherapy notes, I keep “psychotherapy notes” as defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your authorization unless the use or disclosure is:

       a. For my use in treating you.

       b. For my use in training or supervising mental health practitioners to help them                       improve their skills in group, joint, family, or individual counseling or therapy.

       c. For my use in defending myself in legal proceedings instituted by you.

       d. For use by the Secretary of Health and Human Services to investigate my                           compliance with HIPAA.

       e. Required by law and the use or disclosure is limited to the requirements of such law.

       f. Required by law for certain health oversight activities pertaining to the originator of         the psychotherapy notes.

       g. Required by a coroner who is performing duties authorized by law. h. Required to             help avert a serious threat to the health and safety of others

   2. Regarding marketing purposes, I will not use or disclose your protected health                     information for marketing purposes.

   3. Regarding the sale of personal health information, I will not sell your protected health         information in the regular course of my business.



Subject to certain limitations in the law, I can use and disclose your personal health information without your authorization for the following reasons:

  1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

  2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

  3. For health oversight activities, including audits and investigations.

  4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an authorization from you before doing so.

  5. For law enforcement purposes, including reporting crimes occurring on my premises.

  6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

  7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

  8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

  9. Regarding workers' compensation purposes. I may provide your protected health information in order to comply with workers' compensation laws.

  10. Regarding appointment reminders and health related benefits or services, I may use and disclose your protected health information to contact you to remind you that you have an appointment with me. I may also use and disclose your protected health information to tell you about treatment alternatives, or other health care services or benefits that I offer.



Regarding disclosures to family, friends, or others, I may provide your protected health information 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. The opportunity to consent may be obtained retroactively in emergency situations.



You have the following rights regarding your PHI information.  To exercise any of these rights, please submit your request in writing to me.


  • Right of Access to Inspect and Copy.  You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care.  Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you.  I may charge a reasonable, cost-based fee for copies. 

  • Right to Amend.  If you feel that the PHI I have about you is incorrect or incomplete, you may ask to amend the information although I do not have to agree to the amendment.  If I deny your request for amendment, you have the right to file a statement of disagreement with me.  I may prepare a rebuttal to your statement and will provide you with a copy.  Please contact me if you have any questions. 

  • Right to an Accounting of Disclosures.  You have the right to request an accounting of certain of the disclosures that I make of your PHI.  I may charge you a reasonable fee if you request more than one accounting in any 12-month period.

  • Right to Request Restrictions.  You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations.  I am not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment care operations, and the PHI pertains to a health care item or service that you paid for out of pocket.  In that case, I am  required to honored your request for a  restriction.

  • Right to Request Confidential Communication.  You have the right to request that I communicate with you about medical matters in a certain way or at a certain location.  I will accommodate reasonable requests.  I may require information regarding how payment will be handled and specification of an alternative address or other method of contact as a condition for accommodating your request.  I will not ask you for an explanation of why you are making the request.

  • Breach Notification.  If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself.

  • Right to a Copy of this Notice.  You have the right to a copy of this notice.



If you believe I have violated your privacy rights, you have the right to file a complaint in writing with or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257.  There will be no retaliation against you if you choose to file a complaint. 


Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. This notice has listed those rights above.