Notices of Privacy Practices

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Your clinician may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

• “PHI” refers to information in your health record that could identify you.

• “Treatment, Payment, and Health Care Operations”

  • Treatment is when your clinician provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when they consult with another health care provider, such as your primary care physician or care team.

  • Payment is when reimbursement is obtained for your healthcare. Examples of payment are when your clinician or our contracted business associate (Therapy Notes), discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

  • Health Care Operations are activities that relate to the performance and operation of your clinician's practice. Examples of health care operations are quality assessment and improvement activities, business-related matters, such as audits and administrative services, and case management and care coordination.

• “Use” applies only to activities within the office (i.e., residential facility, assisted living, transitional care center, memory care center, etc.), such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of the office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

Your clinician may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when your clinician is asked for information for purposes outside of treatment, payment or health care operations, they will obtain an authorization from you before releasing this information. They will also need to obtain an authorization before releasing your psychotherapy or medical notes. “Psychotherapy or medical notes” are notes about conversations during a private, group, joint, or family counseling session, which are kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) your clinician has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

Your clinician may use or disclose PHI without your consent or authorization in the following

circumstances:

• Child Abuse: If they know or have reason to believe a child is being neglected or physically or sexually abused, or has been neglected or physically or sexually abused within the preceding three years, they must immediately report the information to the local welfare agency, police or sheriff’s department.

• Abuse of a Vulnerable Adult: If they have reason to believe that a vulnerable adult is being or has been maltreated, or if they have knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained, they must immediately report the information to the appropriate agency in the county in which the incident occurred. They may also report the information to a law enforcement agency. “Vulnerable adult” means a person who, regardless of residence or whether any type of service is received, possesses a physical or mental infirmity or other physical, mental, or emotional dysfunction:

(i) that impairs the individual's ability to provide adequately for the individual's own care without assistance, including the provision of food, shelter, clothing, health care, or supervision; and

(ii) because of the dysfunction or infirmity and the need for assistance, the individual has an impaired ability to protect the individual from maltreatment.

• Health Oversight Activities: The Board of Marriage Family Therapy may subpoena records from your clinician if they are relevant to an investigation it is conducting.

• Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that have been provided to you and/or the records thereof, such information is privileged under state law and your clinician must not release this information without written authorization from you or your legally appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered and you will be informed in advance if this is the case.

• Serious Threat to Health or Safety: If you communicate a specific, serious threat of physical violence against a specific, clearly identified or identifiable potential victim, your clinician must make reasonable efforts to communicate this threat to the potential victim or to a law enforcement agency. They must also do so if a member of your family or someone who knows you well has reason to believe you are capable of and will carry out the threat. They also may disclose information about you necessary to protect you from a threat to commit suicide.

• Worker’s Compensation: If you file a worker’s compensation claim, a release of information from your clinician to your employer, insurer, the Department of Labor and Industry, or you will not need your prior approval.

• Incapacitation/Death: In the unlikely event that your clinician is unable to continue providing services without prior notice (such as due to incapacitation or death), a designated professional colleague will access my client contact list solely for the purpose of notifying you and assisting with referrals or continuity of care.

IV . Patient's Rights and Clinician’s Duties

Patient's Rights:

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, your clinician is not required to agree to a restriction you request.

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are receiving services. On your request, any written and mailed communication may be sent to another address.)

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI (and psychotherapy or medical notes) in my mental or medical health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your clinician may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, they will discuss with you the details of the request and denial process.

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record; however, your request may be denied. On your request, your clinician will discuss with you the details of the amendment process.

• Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, will be discussed the details of the accounting process.

• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from your clinician upon request, even if you have agreed to receive the notice electronically.

Clinician’s Duties:

• Your clinician is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.

• Your clinician reserves the right to change the privacy policies and practices described in this notice. Unless they notify you of such changes, however, they are required to abide by the terms currently in effect. 

• If your clinician revises their policies and procedures, they will provide you a copy of the revised notice of policies and practices to protect the privacy of your health information.

V . Effective Date and Changes to Privacy Policy

This notice is effective December 1, 2025. Your clinician reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that they maintain. They will provide you with a revised notice as applicable.