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Psychological Services

Psychological testing and treatment

for Individuals, Couples, and Families.

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Privacy & Policy

Confidentiality & Privacy Policy

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:

  • Suspected child abuse or dependant adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
  • If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
  • If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in insuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.

Your Information. Your Rights.
Our Responsibilities.

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.


Your Rights

When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.

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Get an electronic or paper copy
of your medical record

Ask us to correct your medical record

Request confidential communications

Ask us to limit what we use or share

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

We may say “no” to your request, but we’ll tell you why in writing within 60 days.

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

We will say “yes” to all reasonable requests.
You can ask us not to use or share certain health

information for treatment, payment, or our operations.

We are not required to agree to your request, and we may say “no” if it would affect your care.

If you pay for a service or health care item out- of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.

We will say “yes” unless a law requires us to share that information.

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Get a list
of those with whom we’ve shared information

Get a copy of this privacy notice

Choose someone to act for you

File a complaint
if you feel your rights are violated

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

We will include all the disclosures except for
those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based
fee if you ask for another one within 12 months.

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

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.

We will make sure the person has this authority and can act for you before we take any action.

You can complain if you feel we have violated your rights by contacting us using the information on the back page.

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

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Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

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In these cases,
you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care

Share information in a disaster relief situation Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

Marketing purposes
Sale of your information
Most sharing of psychotherapy notes

We may contact you for fundraising efforts, but you can tell us not to contact you again.

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In these cases we never share your information unless you give us written permission:

In the case of fundraising:

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Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

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Treat you

Run our organization

Bill for your services

We can use your health information and share it with other professionals who are treating you.

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

We can use and share your health information to bill and get payment from health plans or other entities.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Example: We use health information about you to manage your treatment and services.

Example: We give information about
you to your health insurance plan so it will pay for your services.

continued on next page

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Our Uses and Disclosures

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

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Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease
Helping with product recalls
Reporting adverse reactions to medications Reporting suspected abuse, neglect, or

domestic violence
Preventing or reducing a serious threat to

anyone’s health or safety

We can use or share your information for health research.

We 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 we’re complying with federal privacy law.

We can share health information about you with organ procurement organizations.

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Do research

Comply with the law

Respond to
organ and tissue donation requests

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Work with a medical examiner or funeral director

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

Respond to lawsuits and legal actions

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

We can use or share health information about you:

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

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

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Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.

  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

  • We must follow the duties and privacy practices described in this notice and give you a copy of it.

  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

    For more information see: www.hhs.gov/ocr/privacy/hipaa/ understanding/consumers/noticepp.html.

    Changes to the Terms of This Notice

    We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

    This Notice of Privacy Practices applies to the following organizations.

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