Notice of Privacy Statement

I’m dedicated to maintaining the privacy of your personal health information as part of providing professional care. I’m required by law to keep your information private.

This section contains summary information about the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI). HIPAA requires that I provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment, and healthcare operations. This notice explains HIPAA and its application to your personal health information in greater detail.

The law requires that I obtain your signature at the end of your first session acknowledging that I’ve provided you with this information. Please read the sections below that explain your privacy rights under HIPAA before our first meeting. If you have any questions or concerns about your rights or privacy, please speak to me about them at that time.

These two sections explain your rights under HIPAA:

• Your Right to Privacy. Federal laws governing how I use information about your health and healthcare and circumstances under which I may or am required to disclose it.
• Your Rights Regarding Your Healthcare Information. Information from your files that I’m required under federal law to share with you; your right to amend information in your health records; your right to file a complaint if you feel your privacy rights have been violated.

Additional reading on federal laws regarding healthcare information privacy. For further information about HIPAA and your right to privacy regarding healthcare information, visit the U.S. Department of Health and Human Services website.

Your rights under California law. In addition to the information in the above sections, you may have other rights granted to you by the laws of the State of California, and these may be different than the federal laws. For further information on the California state law protecting patient rights, go to the California Healthcare Foundation website.

Additional reading about your rights as a psychotherapy patient. For further information about your rights as a psychotherapy patient, visit the American Psychological Association website.

I will use the information about your health (obtained from you or your other healthcare providers) mainly to provide you with treatment. I will also use it for business activities called healthcare operations. This includes providing you with a monthly billing statement of sessions attended, session payments you have made, a diagnosis / diagnoses, and type of treatment session provided. I will notbe sending the billing statement to any insurance companies (unless you make a special request and sign a form authorizing me to do so). This gives you control over the distribution of your own healthcare transmission to your insurer.

If you or I want to disclose (send, share, or release) your healthcare information for any other purpose, I will discuss it with you and ask that you sign an authorization form to allow this. I cannot disclose this information without your written permission.

Exceptions to my legal / professional obligation to keep your healthcare information private:

• When there is a serious threat to your health or safety or to the health or safety of another individual or the public. (In this case, I would share your information with a person or organization that might be able to prevent or reduce these threats.)
• Some lawsuits and / or court proceedings.
• If a law enforcement official requires me to do so.
• For Workers’ Compensation and similar benefit programs.
• There are some other rare-exception situations in which I may disclose information without your permission: situations in which your records might be needed to investigate a crime; situations in which your records are requested by public health officials for the investigation of diseases or injuries; situations in which you are being investigated by government or military officials; situations after your death.

• You can request that I communicate with you about your health and related issues in a particular way or at a certain place that is more private for you. For example, you can ask that I call you at home and not at work to schedule or cancel an appointment. I will do my best to do as you ask.
• You have the right to limit what I tell people involved in your care or people involved in paying for your care, such as family members and friends.
• You have the right to look at the health information I have about you, such as your medical and billing records. You may even request a copy of these records, but I may charge you for administrative time ($100 per hour, prorated) and copying ($.20 per sheet). Please speak to me directly to make a request to look at your healthcare information.You’re entitled to view the following information: the notations I make regarding the medication prescriptions and monitoring provided to you by another clinician; the modalities and frequency of treatment sessions I have provided for you; the results of clinical tests, self-report forms, or symptom-monitoring sheets in your chart; a written summary (written by me) of your diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date.The only exception to your automatic right to review information in your medical chart is viewing psychotherapy notes I write. There are specific laws governing psychotherapy session notes, because these notes are intended to assist the psychotherapist only and have the potential of being misinterpreted by others. If you would still like to view the psychotherapy notes, please speak with me about this. I will review with you the pros and cons of this, relevant to your treatment needs and situation.
• You have the right to accurate information in your health records. If you believe my records contain incorrect or missing information, you have the right to ask me to make amendments to your records. Please make this request in writing, indicating the reason you want to make these changes, and give the written request to me to place in your medical chart.
• 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 healthcare I provide you.