This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

I. Disclosures for Treatment, Payment, and Health Care Operations: I may use or disclose your protected health information (PHI), for certain treatment, payment, and health care purposes without your authorization. In certain circumstances, I can only do so when the person or business requesting your PHI gives me a written request that includes certain promises regarding protecting the confidentiality of your PHI.

To help clarify these terms, here are some definitions:

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

“Treatment and Payment Operations” “Treatment” is when I provide or another healthcare provider diagnoses or treats you. An example of treatment would be when I consult with another health care provider, such as your family physician or another mental health professional, regarding your treatment.

“Payment” is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process my health care claims or payments.

“Health Care Operations” is when I disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who have provided such services to you. I may also provide your PHI to my accountant, attorney, consultants, or others to further my health care operations.

I may disclose your PHI to remind you about appointments and to inform you of health related benefits or services. “Use” applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

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

“Authorization” means written permission for specific uses or disclosures.

II. Uses and Disclosures Requiring Authorization: I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances, I will obtain an authorization from you before releasing information. You may revoke or modify all such authorizations at any time; however, the revocation or modification is not effective until I receive it in writing.

III. Uses and Disclosures with Neither Consent nor Authorization: I may use or disclose PHI without your consent or authorization in the following circumstances:

1. Child Abuse: Whenever I, in my professional capacity, have knowledge of or reasonably suspect that a child has been the victim of child abuse or neglect, I must report such to Child Welfare Services (CWS) or law enforcement. This includes physical or sexual abuse, child pornography, and a child as the perpetrator of abuse. Also, if I have knowledge of or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional wellbeing is endangered in any other way, I may report such to CWS as well.

2. Elder or Dependent Adult Abuse: If I, in my professional capacity, have observed or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if I am told by an elder or dependent adult that he or she has experienced these or if I reasonably suspect such, I must report the known or suspected abuse to Adult Protective Services (APS) or law enforcement agency. I do not have to report such an incident if: I have been told by an elder/dependent adult that he or she has experienced behavior constituting abuse or neglect, I am not aware of any independent evidence that corroborates the statement, the elder/dependent adult has been diagnosed with or is the subject of a court ordered conservatorship because of a mental illness or dementia, and I reasonably believe that the abuse did not occur.

3. Health Oversight: If a complaint is filed against me with the California Board of Behavioral Sciences, the Board has the authority to subpoena confidential mental health information from me relevant to that complaint. I may have to provide information to assist the government in conducting an investigation or inspection of a health care provider or organization.

4. Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that I have provided you, I must not release your information without

1) your written authorization or the authorization of your attorney or personal representative;

2) a court order; or

3) a subpoena duces tecum (a subpoena to produce records) where the party seeking your records provides me with a showing that you or your attorney have been served with a copy of the subpoena, affidavit and the appropriate notice, and you have not notified me that you are bringing a motion in the court to quash (block) or modify the subpoena. The privilege does not apply when you are being evaluated by a third party or where the evaluation is court-ordered. I will inform you in advance if this is the case.

5. Serious Threat to Health or Safety: If you communicate to me a serious threat of physical violence against an identifiable victim, I must make reasonable efforts to communicate that information to the potential victim and the police. If I have reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, I may release relevant information as necessary to prevent the threatened danger. IV.

Patient’s Rights and Professional Clinical Counselor’s Duties:

1. Patient’s Rights:

a. Right to Inspect and Copy: You are entitled to receive a copy of your medical record unless I believe that receiving that information could be life threatening. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records or receive a copy of your records, I require written notice to that effect, and I would expect to discuss your request with you in person. If I deny you access to your records, you can request to speak with an independent colleague of mine about your request, also to be made in writing. If you are provided with a copy of your medical record information, I may charge a fee for any costs associated with that request.

b. Right to Amend: If you believe that the information I have about you is incorrect or incomplete, you may ask me to amend that information. It is my practice to accept this sort of request in writing, and that any information you may wish to add to your record also be provided to me in written form. I may say “no” to your request, but I will provide you with a reason for doing so.

c. Right to an Accounting of Disclosures: You have the right to request an "Accounting Of Disclosures." This is a list of the disclosures I have made of medical record information. That information is listed on the Authorization To Release Information, and will be provided to you at your written request.

d. Right to Request Restrictions: You have the right to privacy, and to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations.

e. Right to Request Confidential Communications: You have the right to request that I communicate with you only in certain ways. For example, you can ask that I not leave a telephone message for you, or that I only contact you at work or by mail.

f. Complaints Regarding Privacy Rights: If you believe your privacy rights have been violated, you may file a written complaint with me, or with an independent colleague of mine, or 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 www.hhs.gov/ocr/privacy/hipaa/complaints/.

You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint. You have the right to a paper copy of this document. I reserve the right to change my policies as outlined herein. If they change, you will be informed of that change and will be provided with a copy of the current document if desired.

2. Professional Clinical Counselor’s Duties:

a. I am required by law to maintain the privacy of your PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

b. 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.

c. If I revise my policies and procedures, I will provide you with a revised notice either in person or by mail.