How I may use and disclose your health information

Your treatment

• I can use your health information and share it with other professionals who are treating you. I will share information without consent in cases of medical, psychiatric, or other health or safety emergencies. I will also share information without consent when required by law.
• Example: A psychiatrist treating you asks to consult with me about your mental health.

Run my health care operations

• I can use your personal health information to run my practice, improve your care, and contact you when necessary.
• Example: I use your health information to manage your treatment and services.

Bill for your services

• I can use and share your health information to bill and obtain payment from health plans or other entities.
• Example: I give information about you to your health insurance plan so it will pay for your services.

Lawsuits and legal disputes

• If you are involved in a lawsuit, I may disclose health information in response to a court order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Disclosures that require your written consent

Psychotherapy notes

• I keep “psychotherapy notes,” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your written authorization. These notes are given a greater degree of protection than other personal health information.

Other personal health information

• You may want your personal health information shared with family, close friends, or other involved in your care. I will share your information with a signed written consent. You may revoke any such written consent at any time in writing.

I will not use or disclose your health information for marketing purposes or sell your health information in the regular course of my business.

When I am allowed or required to disclosure your health information without consent

I am allowed or required to share your information, usually in ways that contribute to the public good, such as public health and research. I have to meet many conditions in the law before I can share your information for these purposes. For more information see: https://www.hhs.gov/hipaa/for-individuals/index.html.

There may be additional disclosures of your health information that I am required or permitted to make by law without your consent, however the following disclosures are the most common:

Helping with public health and safety issues

• Reporting suspected child or elder abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety, including threats to harm or kill oneself or others (such as threats of suicide or homicide, assault, or other physical damage)
• Duty to warn appropriate individuals when their safety is threatened
• Reporting a crime on my person or property

Complying with the law

• I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that I am complying with federal privacy law.

Working with a medical examiner or funeral director

• I can share health information with a coroner, medical examiner, or funeral director when a client dies.

Addressing workers’ compensation, law enforcement, and other government requests

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Responding to lawsuits and legal actions

• I can share health information about you in response to a court or administrative order or in response to a subpoena, although my preference is to obtain written consent from you before doing so.

Your Rights

Get an electronic or paper copy of your health record

• Other than “psychotherapy notes,” you have a right to get an electronic or paper copy of your health record and other health information I have about you. Ask me how to do this.
• I will provide a copy or a summary of your health information without an unreasonable delay, but generally within 30 days of your request. I may charge a reasonable, cost-based fee.

Ask me to correct your health record

• You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this.
• I may deny your request and provide a written explanation in writing within 60 days.

Request confidential communications

• You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• I will comply with all reasonable requests.

Ask me to limit what I use or share

• You can ask me not to use or share certain health information for treatment, payment, or my operations.
• I am not required to agree to your request, and I may deny it if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer.
• I will comply unless a law requires me to share that information.

Get a list of the disclosures I have made

• You can request a list of the times I have shared your health information for purposes other than treatment, payment, or health care operations, or for which you provided me with written consent. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time.
• I will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

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.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.

File a complaint if you feel your rights are violated

• You can complain if you feel I have violated your rights by contacting me using the “Message Me” button on the bottom of this website.
• You can 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 https://www.hhs.gov/hipaa/filing-a-complaint/.
• I will not retaliate against you for filing a complaint.

My responsibilities

• I am required by law to maintain the privacy and security of your protected health information.
• I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• I must follow the duties and privacy practices described in this notice and give you a copy of it.
• I will not use or share your information other than as described here unless you tell me I can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.