Notice of Privacy Practices





My commitment to your privacy.


My practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care. I am also required by law to keep your information private.

These laws are complicated, but I must give you this important information. This notice is a shorter version of the full, legally required NPP and you may have a copy of this to read and refer to it for more information. However, I can’t cover all possible situations so please talk to me about any questions or problems.

I will use the information about your health which I obtain from you or from others mainly to provide you with treatment, to arrange payment for my services, and for some other business activities which are called, in the law, health care operations. After you have read this NPP, I will ask you to sign a Consent Form to let me use and share your information. If you do not consent and sign this form, I cannot treat you.

If I or you want to use or disclose (send, share, release) your information for any other purposes, I will discuss this with you and ask you to sign an Authorization form to allow this.Of course I will keep your health information private but there are times when the laws require me to use or share it. For example:

1. When there is a serious threat to your health and safety or the health and safety of another individual or the public. I will only share information with a person or organization who is able to help prevent or reduce the threat.

2. Some lawsuits and legal or court proceedings.

3. If a law enforcement official requires to do so.

4. For Workers Compensation and similar benefit programs.

There are some other situations like these which don’t happen very often. They are described in the longer version of the NPP.

Your rights regarding your health information

1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place which is more private for you. For example, you can ask me to call you at home, and not at work to schedule or cancel an appointment. I will try my best to do as you ask.

2. You have the right to ask me to limit what I tell people involved in your care or the payment for your care, such as family members and friends.

3. You have the right to look at or get copies of the health information I have about you such as your medical and billing records, with limited exceptions. You must make your request in writing. I will charge you a reasonable cost-based fee that may include time, copying costs and postage. I will always discuss this with you if it comes up in our work together. You have the right to request that you receive your health information in a specific way or at a specific location. I will comply with your written requests to the extent that I am able to do so.

Psychotherapy Notes: Any psychotherapy process notes that I make are confidential. I am the only person who has access to such notes. The only circumstances under which such notes might be used or disclosed are:

(1) in defense of a legal action brought by the individual whose records are in issue; or (2) as required or authorized by law to enable a health oversight agency (such as Medicare) to oversee the originator of the psychotherapy notes.

4. If you believe the information in your records is incorrect or missing important information, you can ask me to make some kinds of changes (called amending) to your health information. You have to make this request in writing and send it to me. You must tell me the reasons you want to make the changes. I have the right to accept or reject your request. I will always discuss this with you. You also have the right to request a list of any disclosures made from October 15, 2003, on. If you request such a list more often than once a year, I will charge you a reasonable cost-based fee.

5. You have the right to a copy of this notice. If I change this NPP, I will post the new version in my office and you can always get a copy of the NPP.

6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care I provide to you in any way.

If you have any question regarding this notice or my health information privacy policies, please contact me.

The effective date of this notice is 7/1/04.

Also, you may have other rights which are granted to you by the laws of our state and these may be the same or different from the rights described above. I will be happy to discuss these situations with you now or as they arise.