NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE

USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS

INFORMATION. PLEASE REVIEW IT CAREFULLY.

I am required by law to maintain the privacy and security of your protected health

information (“PHI”) and to provide you with this Notice of Privacy Practices (“Notice”). I

must abide by the terms of this Notice, and I must notify you if a breach of your

unsecured PHI occurs. I can 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.

Except for the specific purposes set forth below, I will use and disclose your PHI only

with your written authorization (“Authorization”). It is your right to revoke such

Authorization at any time by giving me written notice of your revocation.

Uses (Inside Practice) and Disclosures (Outside Practice) Relating to Treatment,

Payment, or Health Care Operations Do Not Require Your Written Consent. I can

use and disclose your PHI without your Authorization for the following reasons:

1. For your treatment. I can use and disclose your PHI to treat you, which may

include disclosing your PHI to another health care professional. For example,

if you are being treated by a physician or a psychiatrist, I can disclose your

PHI to him or her to help coordinate your care, although my preference is for

you to give me an Authorization to do so.

2. To obtain payment for your treatment. I can use and disclose your PHI to

bill and collect payment for the treatment and services provided by me to you.

For example, I might send your PHI to your insurance company to get paid for

the health care services that I have provided to you, although my preference

is for you to give me an Authorization to do so.

3. For health care operations. I can use and disclose your PHI for purposes of

conducting health care operations pertaining to my practice, including

contacting you when necessary. For example, I may need to disclose your

PHI to my attorney to obtain advice about complying with applicable laws.

Certain Uses and Disclosures Require Your Authorization.

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is

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 other 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. Marketing Purposes. As a psychotherapist, I will not use or disclose your

PHI for marketing purposes.

3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular

course of my business.

Certain Uses and Disclosures Do Not Require Your Authorization. Subject to

certain limitations in the law, I can use and disclose your PHI 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. For workers' compensation purposes. Although my preference is to obtain an

Authorization from you, I may provide your PHI in order to comply with

workers' compensation laws.

10. Appointment reminders and health related benefits or services. I may use and

disclose your PHI to contact you to remind you that you have an appointment

with me. I may also use and disclose your PHI to tell you about treatment

alternatives, or other health care services or benefits that I offer.

Certain Uses and Disclosures Require You to Have the Opportunity to Object.

1. Disclosures to family, friends, or others. I may provide your PHI 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.

YOUR RIGHTS YOUR REGARDING YOUR PHI

You have the following rights with respect to your PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You

have the right to ask me not to use or disclose certain PHI for treatment,

payment, or health care operations purposes. I am not required to agree to

your request, and I may say “no” if I believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for

In Full. You have the right to request restrictions on disclosures of your PHI

to health plans for payment or health care operations purposes if the PHI

pertains solely to a health care item or a health care service that you have

paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me

to contact you in a specific way (for example, home or office phone) or to

send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy

notes,” you have the right to get an electronic or paper copy of your medical

record and other information that I have about you.

I will provide you with a copy of your record, or a summary of it, if you agree

to receive a summary, within 30 days of receiving your written request, and I

may charge a reasonable, cost based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made.

You have the right to request a list of instances in which I have disclosed your

PHI for purposes other than treatment, payment, or health care operations, or

for which you provided me with an Authorization.

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 the list to

you at no charge, but if you make more than one request in the same year, I

will charge you a reasonable cost based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a

mistake in your PHI, or that a piece of important information is missing from

your PHI, you have the right to request that I correct the existing information

or add the missing information. I may say “no” to your request, but I will tell

you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the

right get a paper copy of this Notice, and you have the right to get a copy of

this notice by e-mail. And, even if you have agreed to receive this Notice via

e-mail, you also have the right to request a paper copy of it.

HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES

If you think I may have violated your privacy rights, you may file a complaint with me, as

the Privacy Officer for my practice, and my address and phone number are:

.

You can also file a complaint with the U.S. Department of Health and Human Services

Office for Civil Rights by:

1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C.

20201;

2. Calling 1-877-696-6775; or,

3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

I will not retaliate against you if you file a complaint about my privacy practices.