NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. 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 health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information.
I am required by law to:
Make sure that protected health information (“PHI”) that identifies you is kept private.
Let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
Give you this notice of my legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.
I will not use or share your information other than as described in this notice unless you tell us we can in writing. If you give consent, you may change your mind at any time. Let me know in writing if you change your mind.
I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment, Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Billing: Your health information may be used or shared to bill and get payment from health plans or other entitites.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities authorized by law, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order or in response to a subpeona. However, my preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others. I may provide your PHI 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.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
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.
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 a health care service that you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that 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, and I may charge a reasonable, cost based fee for doing so.
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 request for an accounting of disclosures within 60 days of receiving your request. 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.
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 from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Choose Someone to Act for You. If someone If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. I will make sure the person has this authority and can act for you before we take any action.
The Right to File a Complaint if You Feel Your Rights are Violated. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html. You will not be retaliated against for filing a complaint.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
VII. Special Protections for Substance Use Disorder Records
IMPORTANT: Federal law and regulations provide special privacy protections for
records related to substance use disorder (SUD) assessment, treatment, and referral.
These protections are governed by 42 C.F.R. Part 2 and apply in addition to HIPAA protections.
1. Scope of Protection
If you receive or have received treatment, evaluation, or referral for a substance use disorder at
our practice, federal law (42 U.S.C. § 290dd-2) and its implementing regulations at 42 C.F.R.
Part 2 strictly limit our ability to disclose any information that would identify you as having or
having had a substance use disorder, or as having received related services.
2. What Requires Your Written Consent
Under Part 2, we generally may NOT disclose your substance use disorder records without your
written consent, even to other healthcare providers, EXCEPT in the limited circumstances
described in section 3 below. Disclosures permitted by HIPAA alone are generally not
sufficient to authorize disclosure of Part 2-protected records.
Your written consent for disclosure of SUD records must specify:
• The name of the person or organization to whom disclosure is made
• The name of the patient
• The purpose of the disclosure
• How much and what kind of information will be disclosed
• A statement that the information may not be re-disclosed without further consent (unless
permitted by Part 2)
• Your signature and the date
• An expiration date or event
3. Exceptions — When Disclosure May Occur Without Consent
Your SUD records may be disclosed without your written consent only in the following limited
circumstances:
• Medical emergencies: To medical personnel who need the information to treat an
immediate medical emergency threatening your life
• Research, audit, or evaluation: To qualified researchers, auditors, or program evaluators
under strict confidentiality agreements
• Court order: Pursuant to a specific court order that meets the requirements of 42 C.F.R.
§ 2.64, and only after the court has reviewed the application in camera
• Crimes on program premises or against program personnel: To report or to investigate a
crime committed on the premises of our practice or against our staff, limited to the
circumstances and extent permitted by Part 2
• Child abuse reporting: As required by mandatory reporting laws
2020 and 2024 Part 2 Amendments
1. Significant amendments to 42 C.F.R. Part 2 took effect in 2020 and 2024, aligning Part 2 more
closely with HIPAA while maintaining additional protections. Key changes include:
• Patients may now provide a single consent for all future disclosures of SUD records to
treating providers and payers, rather than requiring a new consent for each disclosure
• Lawful holders of Part 2 records may now re-disclose records with patient consent to
other HIPAA-covered entities and business associates for payment and healthcare
operations purposes
• Records may be used in civil, criminal, or administrative proceedings involving a crime
against the patient or a threat to patient safety, subject to court-ordered protections
• All recipients of Part 2 information who are HIPAA-covered entities must comply with
both HIPAA and Part 2
Your Rights Regarding SUD Records
You have the right to:
• Revoke your consent to disclose SUD records at any time, except to the extent that
action has already been taken in reliance on your consent
• Receive a copy of your consent form
• Request that SUD records not be disclosed to specific persons or entities
Violation of 42 C.F.R. Part 2 is a federal criminal offense. Violations may be reported to the
United States Attorney for the district in which the violation occurred.
VIII. Special Protections for Reproductive Health Information
IMPORTANT: Federal regulations issued in 2024 under the HIPAA Privacy Rule
impose new, significant restrictions on the use and disclosure of protected health
information related to reproductive health care.
Overview of New Reproductive Health Privacy Rule
On April 26, 2024, the U.S. Department of Health and Human Services (HHS) finalized a rule
(effective June 25, 2024, with compliance required by December 23, 2024) amending the
HIPAA Privacy Rule to strengthen privacy protections for PHI related to reproductive health
care.
2. What Is Reproductive Health Care
For purposes of this Notice, reproductive health care includes any health care that affects the
reproductive system or that is sought for purposes related to reproduction. This includes, but is
not limited to:
• Contraception, including emergency contraception
• Fertility and infertility treatments
• Pregnancy-related care, including prenatal and postnatal care
• Miscarriage management
• Abortion and abortion-related care
• Sterilization procedures
• Care for conditions related to reproductive health (e.g., endometriosis, PCOS)
• Sexually transmitted infection (STI) treatment and prevention
3. Prohibited Uses and Disclosures
Under the 2024 amendments, we are PROHIBITED from using or disclosing your reproductive
health PHI for the following purposes:
• To conduct a criminal, civil, or administrative investigation of any person for the mere act
of seeking, obtaining, providing, or facilitating lawful reproductive health care
• To impose criminal, civil, or administrative liability on any person for the mere act of
seeking, obtaining, providing, or facilitating lawful reproductive health care
• To identify any person for these investigative or liability purposes
These prohibitions apply regardless of whether the care was received within or outside the state
where it is being investigated or where the patient resides.
4. Attestation Requirement
When we receive a request for reproductive health PHI for certain purposes — including law
enforcement, judicial and administrative proceedings, or health oversight activities — we are
required to obtain a signed attestation from the requesting party stating that the use or
disclosure is not for a prohibited purpose. We will not release reproductive health PHI in
response to such requests without this attestation.
4. Your Rights Regarding Reproductive Health PHI
In addition to your general rights under HIPAA (see Section 7 below), you have the right to:
• Expect that your reproductive health information will not be shared with law enforcement
or courts for the purpose of investigating or prosecuting anyone for seeking or providing
lawful reproductive health care
• Have your reproductive health care information treated with the same confidentiality as
other sensitive health information
• Request an accounting of disclosures of your reproductive health PHI
Interaction with State Law
Where state law provides greater privacy protections for reproductive health information than
federal law, we will comply with the more protective state law. Patients receiving services in
California or other states with strong reproductive health privacy laws may have additional rights
and protections beyond those described here.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on 2/16/2026