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Privacy Practices


This notice went into effect on March 15, 2017.


I take your privacy very seriously. I understand that protected health information (PHI) about you and your health care is personal, and I am committed to protecting your PHI. I keep a record of the care and services you receive from me and of our communications in and outside of sessions. 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 mental health care practice. This notice will tell you about the ways in which I may use and disclose PHI about you. It also describes your rights to the PHI I keep about you and certain obligations I have regarding the use and disclosure of your PHI. I am required by law to:

  1. Make sure that PHI about you is kept private.

  2. Give you this notice of my legal duties and privacy practices with respect to your PHI.

  3. Follow the terms of the notice that is currently in effect.

Please note, I can change the terms of this Notice. Such changes will apply to all PHI I have about you when the new Notice is made available upon request, in my office, and on my website.

The following categories describe different ways that I may use and disclose your PHI without your written authorization.

1. For Treatment, Payment, or Health Care Operations: I may use PHI about you to provide you with, coordinate, or manage your health care treatment or services. I may disclose PHI to other providers or people who are involved in your care, typically with your consent. I may use and disclose PHI to contact you as a reminder that you have an appointment. I may use and disclose PHI to tell you about or recommend possible treatment options, alternatives, health-related benefits, or services that may be of interest to you. I may use and disclose PHI about you so that the treatment and services you receive from me may be billed to and payment may be collected from you, an insurance company, or a third party. I may use and disclose PHI about you for health care operations, such as quality assessment and improvement activities, case management, coordination of care, customer services and other activities. These uses and disclosures are necessary to make sure that all patients receive quality care. For example, I may use PHI with other independent practitioners for consultation, review, and learning purposes but will remove personal identifiers (such as your name) to protect your identity. Subject to applicable state law, in some limited situations the law allows or requires me to use or disclose your PHI for purposes beyond treatment, payment, and operations.

2. As Required By Law: I will disclose PHI about you when required to do so by federal, state, or local law.

3. To Avert a Serious Threat to Health or Safety: I may use and disclose PHI about you when necessary to prevent a serious threat to the health and safety of you or another person.

4. Public Health: As required by law, I may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

5. Health Risks: I may disclose PHI about you to a government authority if I reasonably believe you or someone you tell me about is a victim of abuse, neglect, or domestic violence. I will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and I believe it is necessary to prevent or lessen a serious and imminent threat to you or another person.

6. Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose PHI about you or your child in response to a court or administrative order, subpoena, discovery request, or other lawful process by someone involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the PHI requested. I may use or disclose your PHI to defend myself in legal proceedings instituted by you.

7. Research: I may disclose your PHI to researchers when their research has been approved by an Institutional Review Board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

8. Business Associates: I may disclose information to business associates who perform services on my behalf (such as billing companies). Business associates are also required to appropriately safeguard your information.

9. Health Oversight Activities: I may disclose PHI to a health oversight agency for activities authorized by law such as audits, investigations, and inspections, as necessary for licensure and for the government to monitor the health care
system, government programs, and compliance with civil rights laws.

10. Law Enforcement: I may release PHI as required by law, or in response to a court order, warrant, subpoena, or administrative request. I may also disclose PHI related to crimes that occur on my premises.

11. Special Government Functions: If you are in the armed forces, I may release PHI about you if it relates to military and veterans activities. I may also release your PHI for national security and intelligence purposes, protective services for the President, and medical suitability or determinations of the Department of State.

12. Correctional Institutions and Other Law Enforcement Custodial Situations: If you are in the custody of a correctional institution or law enforcement official, I may release PHI about you to the correctional institution/law enforcement official as necessary for your or another person’s health and safety.

13. Coroners, Medical Examiners, and Funeral Directors: I may release PHI to a coroner or medical examiner when necessary to identify a deceased person or determine cause of death. I may also disclose PHI to funeral directors consistent with applicable law.

14. Organ and Tissue Donation: If you are an organ donor, I may release PHI to organizations that handle organ/eye/tissue procurement or transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

15. Worker’s Compensation: I may disclose PHI as necessary to comply with laws relating to worker’s compensation.

16. Food and Drug Administration: I may disclose PHI related to adverse events with respect to drugs, foods, supplements, products and product defects.


1. Disclosures to family, friends, or others: I may provide PHI about you 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.


I will obtain your written authorization before using or disclosing your PHI for purposes other than those provided for above (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, I will stop using or disclosing your PHI, except to the extent that I have already done so.


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 service that you have paid for out-of-pocket in full.

3. The Right to Choose How PHI Is Communicated: You have the right to ask me to contact you in a specific way or at a specific location (for example, mail to you home or call your office phone only). I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI: You have the right to get an electronic or paper copy of your medical record and other information 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. I may charge a reasonable, cost-based fee for doing so. There are some circumstances in which I do not have to comply with your request. In those cases, I will explain in writing the reason for denial and options for appeal.

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 written request for an accounting of disclosures within 60 days of receipt. 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, you have the right to request a correction. Your request must be made in writing. 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 to get a paper or electronic copy of this Notice.



If you believe your privacy rights have been violated, you may file a complaint with me or file a written complaint with the Secretary of the Department of Health and Human Services. A complaint to the Secretary should be filed within 180 days of the occurrence or action that is the subject of the complaint. If you file a complaint, I will not take any action against you or change my treatment of you in any way.

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. 

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