THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for
Treatment, Payment, and Health Care Operations
I may use or disclose your protected health
information (PHI), for treatment, payment, and health
care operations purposes with your consent. To help clarify
these terms, here are some definitions:
“PHI” refers to information in your health record that could
“Treatment, Payment and Health Care Operations”
– Treatment is when I provide,
coordinate or manage your health care and other services related to
your health care. An example of treatment would be when I consult with
another health care provider, such as your family physician or another
- Payment is when I obtain
reimbursement for your healthcare. Examples of payment are when I
disclose your PHI to your health insurer to obtain reimbursement for
your health care or to determine eligibility or coverage.
- Health Care Operations are
activities that relate to the performance and operation of my
practice. Examples of health care operations are quality assessment
and improvement activities, business-related matters such as audits
and administrative services, and case management and care
“Use” applies only to activities within my practice, such as
sharing, employing, applying, utilizing, examining, and analyzing
information that identifies you.
“Disclosure” applies to activities outside of my practice, such
as releasing, transferring, or providing access to information about
you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment,
and health care operations when your appropriate authorization is
obtained. An “authorization” is written permission above and
beyond the general consent that permits only specific disclosures. In
those instances when I am asked for information for purposes outside
of treatment, payment and health care operations, I will obtain an
authorization from you before releasing this information. I will also
need to obtain an authorization before releasing your psychotherapy
notes. “Psychotherapy notes” are notes I have made about our
conversation during a private, group, joint, or family counseling
session, which I have kept separate from the rest of your medical
record. These notes are given a greater degree of protection than
You may revoke all such authorizations (of PHI or psychotherapy notes)
at any time, provided each revocation is in writing. You may not
revoke an authorization to the extent that (1) I have relied on that
authorization; or (2) if the authorization was obtained as a condition
of obtaining insurance coverage, and the law provides the insurer the
right to contest the claim under the policy.
III. Uses and Disclosures with
Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the
If I have reasonable cause to believe that a child has suffered abuse
or neglect, I am required by law to report it to the proper law
enforcement agency or the Washington Department of Social and Health
Adult and Domestic Abuse:
If I have reasonable cause to believe that abandonment, abuse,
financial exploitation, or neglect of a vulnerable adult has occurred,
I must immediately report the abuse to the Washington Department of
Social and Health Services. If I have reason to suspect that sexual or
physical assault has occurred, I must immediately report to the
appropriate law enforcement agency and to the Department of Social and
If the Washington Examining Board of Psychology subpoenas me as part
of its investigations, hearings or proceedings relating to the
discipline, issuance or denial of licensure of state licensed
psychologists, I must comply with its orders. This could include
disclosing your relevant mental health information.
Judicial or Administrative Proceedings:
If you are involved in a court
proceeding and a request is made for information about the
professional services that I have provided to you and the records
thereof, such information is privileged under state law, and I will
not release information without the written authorization of you or
your legal representative, or a subpoena of which you have been
properly notified and you have failed to inform me that you are
opposing the subpoena, or a court order. The privilege does not apply
when you are being evaluated for a third party or where the evaluation
is court ordered. You will be informed in advance if this is the case.
Serious Threat to Health or Safety:
I may disclose your confidential mental health information
to any person without authorization if I reasonably believe that
disclosure will avoid or minimize imminent danger to your health or
safety, or the health or safety of any other individual.
If you file a worker's compensation claim, with certain exceptions, I
must make available, at any stage of the
proceedings, all mental health information in my possession relevant
to that particular injury in the opinion of the Washington Department
of Labor and Industries, to your employer, your representative, and
the Department of Labor and Industries upon request.
IV. Patient's Rights and
Right to Request Restrictions
–You have the right to request restrictions on certain uses and
disclosures of protected health information about you. However, I am
not required to agree to a restriction you request.
Right to Receive
Confidential Communications by Alternative Means and at Alternative
Locations – You have the right to request and receive
confidential communications of PHI by alternative means and at
alternative locations. (For example, you may not want a family member
to know that you are seeing me. Upon your request, I will send your
bills to another address.)
Right to Inspect and Copy
– You have the right to inspect or obtain a copy (or both) of PHI and
psychotherapy notes in my mental health and billing records used to
make decisions about you for as long as the PHI is maintained in the
record. I may deny your access to PHI under certain circumstances, but
in some cases you may have this decision reviewed. On your request, I
will discuss with you the details of the request and denial process.
Right to Amend
– You have the right to request an amendment of PHI for as long as the
PHI is maintained in the record. I may deny your request. On your
request, I will discuss with you the details of the amendment process.
Right to an Accounting
– You generally have the right to receive an accounting of disclosures
of PHI for which you have neither provided consent nor authorization
(as described in Section III of this Notice). On your request, I will
discuss with you the details of the accounting process.
Right to a Paper Copy
– You have the right to obtain a paper copy of the notice from me upon
request, even if you have agreed to receive the notice electronically.
I am required by law to maintain the privacy of PHI and to provide you
with a notice of my legal duties and privacy practices with respect to
I reserve the right to change the privacy policies and practices
described in this notice. Unless I notify you of such changes,
however, I am required to abide by the terms currently in effect.
If I revise my policies and procedures, I will notify you by mail with
a revised version of this document.
If you are concerned that I have violated your privacy rights, or you
disagree with a decision I made about access to your records, please
contact me at my business address.
You may also send a written complaint to the Secretary of the U.S.
Department of Health and Human Services. Office of Civil Rights, 200
Independence Ave. SW, Washington, D.C. 20201 (877-696-6775 toll
VI. Effective Date, Restrictions
This notice will go into effect on 4-15-03. I reserve the right to
change the terms of this notice and to make the new notice provisions
effective for all PHI that I maintain. I will provide you with a
revised notice by mail.