Health Insurance Portability and Accountability Act (HIPAA) - PRIVACY NOTICE

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

In this Privacy Notice, “medical information” and “psychological information” mean the same as “fiealth information.” Health information includes any information that relates to:

  1. your past, present, or future physical or mental health or condition;
  2. providing health care to you; or
  3. the past, present, or future payment for your health care.


Protecting Your Priva :

Counselors must always manage psychological records with great concern for privacy and confidentiality. I am required by law to protect the privacy of your health information. This means that I will not use or disclose your health information without your authorization except in the ways I tell you in this notice. If 1 wish to use or disclose your health information in ways other tfian those stated in this notice, I will ask you for your written authorization. If you give such an authorization, you may revoke it at any time, but I wil[ not be liable for uses or disclosures made before you revoked your authorization.


Although the security of psychological records has continuously been addressed by Counseling Codes of Ethics as well as by State and Federal laws, the rules have been considerably strengthened by the provisions of the Health Insurance Portability and Accountability Act (HIPAA). The following information provides details about the provisions of HIPAA and your rights concerning privacy and your psychological records.


Who will observe these rules?

In my practice, the following individuals are required by HIPAA to comp[y with the privacy rules:

  • Nle and any practice staff such as office manager/scheduler, etc..
  • Any billing agency or collection agency that handles information about you (name and address, diagnostic codes, treatment codes, and consultation dates…but not actual clinical records)



  1. The Right to Inspect and Obtain a Copy of Your Psychological Record Professional records constitute an important part of the therapy process and help with the continuity of care over time. According to the rules of HIPAA, your consultations are documented in two ways: 1) The Clinical Record (required), which includes the date of your consultations, your reasons for seeking therapy, your diagnosis, therapeutic goals, treatment plan, progress, medica I and social history, treatment history, functional status, any past records from other providers, and any reports to your insurance carrier; and 2) Psychotherapy Notes (optional), which consist of specific content or analyses of therapy conversations (some of which may include sensitive information you have revealed that is not required to be included in your Clinical Record) and therapist’s notes that may assist in treatment. Psychotherapy Notes, if created, are never disclosed to third parties, HM0s, insurance companies, billing agencies, patients, or anyone else. If your case manager or insurance company requests to see the psychotherapy notes, you have a choice about consenting (signing a Release of Information form) or denying access to them. If you refuse, it wiII not affect your coverage or reimbursement in any way, and your insurance company or HM0 is ob(iged to provide payment, as usual.
  2. The Right to Request a Correction or Add an Addendum to Your Psycho logical Record Correction
  3. The Right to an Accounting of Oisc losures of Your Psychological Information to Third Parties
  4. The Right to Request Restrictions on How Your Informatio n is Used
  5. The Right to Request Confidential Communications
  6. The R ight to a Copy of This Notice upon Request
  7. The Right to Withdraw Permission to Disclose Health Information
  8. The R ight to File a Complaint You have the right to file a complaint if you believe your privacy rights have been Complaints must be filed in writing, and may be addressed directly to your therapist, or to the Secretary of the Department of Health and Human Services (address: Office for Civil R ights, 200 Independence Ave., S.W. Washington, DC 20201). If you have any questions or concerns about this notice or your hea lth information privacy, please do not hesitate to address them during session or contact my office by telephone.
  9. The Right to be Notified in There is a Breach of Your Unsecured PH} You haye a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of tfie HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) our risk assessment fails to determine that there is a low probability that your PHI fias been compromised.
  10. The Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocke-t You have the right to restrict certain disc losures of PHI to a health plan when you pay out-of-pocker in full for services.


My signature above represents that I have read and understand my rights under HIPAA.                                           Date