To my clients: This notice describes how health information about you (as a client of my practice) may be used and disclosed and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

COMMITMENT TO YOUR PRIVACY

 My practice is dedicated to maintaining the privacy of your health information. I am required by law to provide you with the following important information explaining your rights and my obligation to maintain your privacy.

USES AND DISCLOSURES REQUIRING AUTHORIZATION

 Your signature on the agreement to enter into treatment with me provides consent for me to use or disclose your protected health information (PHI) in the course of treatment, payment and health care operations purposes. This would include consultations with other professionals who are also legally bound to keep the information confidential; any clinical or administrative personnel responsible for billing; and any contract I may have with an agency associated with your care and health service, which promises to maintain confidentiality except as specifically allowed in the contract or otherwise required by law.

With your permission and written authorization, I may release information for other purposes. When I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain authorization from you before releasing this information. You may revoke all such authorizations at any time, in writing, unless 1) I have taken action in reliance on it; or 2) if the authorization was obtained as a condition of obtaining insurance coverage; or 3) if you have not satisfied any financial obligations you have incurred.

USES AND DISCLOSURES REQUIRING NEITHER CONSENT NOR AUTHORIZATION

I may use or disclose PHI without your consent or authorization in the following circumstances:

• Harm or Abuse: When necessary to reduce or prevent a serious threat to your health and safety, or the health and safety of another individual or the public. I am required to report any suspicion of child abuse, adult or domestic abuse to the appropriate authorities.
• Health Oversight: To public health authorities and health oversight agencies that are authorized by law to collect information.
• Judicial or Administrative Proceedings: Privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered, and I am required to release information.
• National Security: If you are a member of US or foreign military forces (including veterans) and if required by the appropriate authorities; to federal officials for intelligence and national security activities authorized by law.
• Law Enforcement Officials: To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.
• Worker’s Compensation: I may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier for Worker’s Compensation or similar programs.

 YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Communications: You can request that my practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that I contact you at home rather than at work. I will accommodate reasonable requests.

Restrictions: You can request a restriction in my use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that I restrict disclosure of your health information to only certain individuals involved in your care or the payment of your care. I am not required to agree with your request. However, if I do agree, I am bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

Inspect and Copy: You have the right to inspect or obtain a copy of the health information that may be 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.

Amend: You have the right to request an amendment of your health information if you believe it is incorrect or incomplete, as long as this information is kept by and for my practice. Your request must be made in writing and submitted to me at the address on the letterhead. You must provide a reason that supports your request. I may deny your request, however.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with my practice or with the Secretary of the Department of Health and Human Services. To file a complaint with my practice, contact me at the address on the letterhead. All complaints must be in writing. You will not be penalized for filing a complaint.

Other Authorization and Accounting: My practice will obtain your written authorization for uses and disclosures not identified by this notice or permitted by

Applicable law: You generally have the right to receive an accounting of any disclosures of your information which were made without your consent or authorization.

If you have any questions regarding this notice or my health information privacy policies, please contact me at the phone number on the letterhead. 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.