NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am
committed to protecting health information about you. I create a record of the care and
services you receive from me. I need this record to provide you with quality care and to
comply with certain legal requirements. This notice applies to all of the records of your care
generated by this practice. This notice will tell you about the ways in which I may use and
disclose health information about you. I also describe your rights to the health information I
keep about you, and describe certain obligations I have regarding the use and disclosure of
your health information. I am required by law to:
• Make sure that protected health information (“PHI”) that identifies you is kept
private.
• Give you this notice of my legal duties and privacy practices with respect to health
information.
• Follow the terms of the notice that is currently in effect.
• 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.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information.
For each category of uses or disclosures I will explain what I mean and try to give some
examples. Not every use or disclosure in a category will be listed. However, all of the ways I
am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow
health care providers who have direct treatment relationship with the patient/client to use
or disclose the patient/client’s personal health information without the patient’s written
authorization, to carry out the health care provider’s own treatment, payment or health care
operations. I may also disclose your protected health information for the treatment activities
of any health care provider. This too can be done without your written authorization. For
example, if a health care provider were to consult with another licensed health care provider
about your condition, we would be permitted to use and disclose your personal health

information, which is otherwise confidential, in order to assist the health care provider in
diagnosis and treatment of your condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard.
Because other health care providers need access to the full record and/or full and complete
information in order to provide quality care. The word “treatment” includes, among other
things, the coordination and management of health care providers with a third party,
consultations between health care providers and referrals of a patient for health care from
one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in
response to a court or administrative 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.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
1. Session Notes: I do keep “Session notes” 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 associates to help them improve their
clinical skills.
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 session 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 health care provider, I will not use or disclose your PHI
for marketing purposes.
3. Sale of PHI. As a health care provider, I will not sell your PHI in the regular course
of my business.

IV. 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 patients who
received one form of care versus those who received another form of care 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 counterintelligence 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.

V. 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.

VI. 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 “session 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.

EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on 2/8/2021.
Acknowledgement of Receipt of Privacy Notice
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. By
checking the box below, you are acknowledging that you have received a copy of HIPAA
Notice of Privacy Practices.