Right to Privacy
Health care providers are required by federal and state law to maintain the privacy of your treatment information. We are also required to give you notice about our privacy practices, our legal duties, and your rights concerning your treatment information.
I must follow the privacy practices that are described while they are in effect (they went into effect September 23, 2013). I reserve the right to change my privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. You may request a copy of the notice at any time from me.
Use and Disclosures of Treatment Information
I will use information about your health care to provide you with treatment, to arrange payment for my services, and in conjunction with other health care providers, organizations, and professionals. The information privacy practices in this notice will be followed by any associate involved in your care and any business associate with whom I share health information.
Examples include:
- Treatment: I may discuss your treatment information with another mental health professional or provider.
- Payment: I may use/disclose your information to obtain payment for services, including billing and collections.
- Legal Proceedings: I may disclose information for legal purposes such as subpoenas or court orders.
- Scheduling: I may use your contact information to schedule or confirm appointments.
- Abuse/Victim Cases: I may disclose information to authorities if there is suspected abuse or serious threat to safety.
- If required by another provider or insurer, I may obtain authorization from you before fulfilling such requests.
I will not disclose your treatment information if that disclosure is prohibited or significantly limited by applicable law. If a breach of your unsecured protected health information occurs, you will be notified.
Your Health Information Rights
You have the right to:
- Inspect or copy treatment information with limited exceptions, by written request.
- Request restrictions on uses/disclosures for treatment, payment, or healthcare operations (though I am not required to agree).
- Request changes to your treatment record in writing with reasons why the info should be amended.
- Receive a list of instances your data was disclosed (for reasons other than treatment/payment).
- Request contact by alternative means or locations (e.g., only at work).
- Request a paper copy of this notice at any time.
Questions and Complaints
If you believe your privacy rights have been violated, you may file a complaint with me or the U.S. Dept. of Health and Human Services:
www.hhs.gov/ocr/privacy/hipaa/complaints/index.html.
There will be no retaliation for filing a complaint.
PLEASE SIGN THE ATTACHED SIGNATURE FORM TO INDICATE YOUR RECEIPT AND AGREEMENT TO THE TERMS INDICATED ABOVE.
Acknowledgement of Receipt of the Virginia Notice Form and Services Agreement
I acknowledge receipt of the Virginia Notice form entitled Notice of Psychologist’ Policies and Practices to Protect the Privacy of Your Health Information and the Psychotherapy Patient Services Agreement. Written acknowledgment of this notice is mandated by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
