NOTICE OF PRIVACY PRACTICES





THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW

YOU GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.



The Notice describes how your mental health information is protected and what rights you have

regarding it. 



Treatment, Payment, and Health Care Operations



	The most common reason why mental health information is disclosed is for treatment,

payment or mental health care operations. Examples of how information is used or disclosed for 

treatment purposes are: setting up an appointment, evaluations, testing; referring you to a 

medical doctor or clinic, or other sources of payment preparing and sending bills or claims;

and collecting unpaid amounts (either ourselves or though a collection agency or attorney). 

"Health care operations" means those administrative and managerial functions that I have to

do. Examples of how I use or disclose your information for health care operations are: 

financial or billing audits; internal quality assurance; participation in managed care 

plans and defense of legal matters.



 

USE AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION



In some limited situations, the law allows or requires me to use or disclose your information

without your permission. Not all of these situations will apply to us; some may never come to my 

practice at all. Such uses or disclosures are:





	· When a state or federal law mandates that certain information be reported;





	· Disclosure to governmental authorities about victims of suspected abuse, neglect or 

          domestic violence;



	· Uses and disclosures for health oversight activities, such as for audits by Medicare

          or Medicaid; or for investigation of possible violations of health care law;



	· Disclosures for judicial and administrative proceedings of health care laws;





	· Uses and disclosures to prevent a serious threat to health or safety;



	· Disclosures relating to worker's compensation programs;



	· Disclosures of a "limited data set" for research, public health, or 

          health care operations;



	· Incidental disclosures that are an unavoidable by-product of permitted

          uses or disclosures;



APPOINTMENT REMINDERS



I may call or write to remind you of scheduled appointments.



OTHER USES AND DISCLOSURES



	I will not make any other uses or disclosures of your health information

unless you sign a written "authorization form." Federal law determines the content

of an "authorization form." Sometimes, I may initiate the authorization process if 

the use or disclosure is my idea. Sometimes, you may initiate the process if it is 

your idea for us to send your information to someone else. Typically, in this 

situation, you give us a properly completed authorization form, or you can use one

of ours. 



If I initiate the process and ask you to sign an authorized form, you do not have

to sign it. If you do not sign one, you may revoke it at any time unless we have

already acted in reliance upon it, revocations must be in writing. Send them to

the office contact person named at the beginning of this Notice.



YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION



	The law gives you many rights regarding your health information. You can:



	· Ask us to restrict my uses and disclosures for purposes of treatment

          (except emergency treatment), payment or health care operations. 



	· Ask to see or get photocopies of your health information. By law, there

 	  are a few limited situations in which we can refuse to permit access or

 	  copying. For the most part, however, you will be able to review or have 

          a copy of your health information within 30 days of asking us (or sixty

          days if the information is stored off-site). You may have to pay for 

          photocopies in advance. If we deny your request, we will send you a written           
          
          explanation, and instructions about how to get an impartial review of our 

          denial. By law, we can have one 30-day extension of the time for us to give

          you access or photocopies if we notify you in writing of the extension. If

          you want to ask us to amend your health information, send a written request,

          including your reasons for the amendment, or the contact person at the address,

          fax or E-mail shown at the beginning of this Notice. 



	· Ask me to amend your health information if you think that is incorrect or

          incomplete. If we agree, we will amend the information within 60 days from 

          when you ask us. I will send the corrected information to persons who we 

          know got the wrong information, and others you specify. If we do not agree,

          you can write a statement of you position, and we will include it with you

          health information among with any rebuttal statement that we may write. 

          Once your statement of position and/or our rebuttal is included in your health           
          
          information, we will send it along whenever we make a permitted disclosure your

          health information. By law, I can have one 30-day extension of time to consider a           
          
          request for amendment if I notify you in writing of the extension. If you want

          to ask me to amend your health information, send a written request, including

          your reasons for the amendment, to the office contact person at the address, 

          fax or E-mail shown at the beginning of this Notice.



	· Get a list of the disclosures that I have made of you health information 

          within the past six years (or a shorter period if you want). By law, the

          list will not include: disclosures for purposes of treatment, payment or

          health care operations; disclosures with your authorization; incidental 

          disclosures; disclosures required by law; and some other limited disclosures.

          You are entitled to one such list per year without charge. If you want more

          frequent lists, you will have to pay for them in advance. I will usually respond

          to your request within 60 days of receiving it, but by law I can have one 30-day           
          
          extension of time if I notify you of the extension in writing. If you want a list, 

          send a written request to the office contact person at the address, fax or E-mail

          show at the beginning of this Notice.



	· Get additional paper copies of this Notice of Privacy Practices upon request. It

          does not matter whether you got one electronically 



 NOTICE OF PRIVACY PRACTICES



By law, I must abide by the terms of this Notice of Privacy Practice until I choose to change 

it. I reserve the right to change this notice at any time as allowed by law. If I change 

this Notice, the new privacy practices will apply to your health information that I already

have as well as to such information that I may generate in the future. If I change my Notice

of Privacy Practices, I will have copies available and post it on my Web site.



COMPLAINTS



If you think that I have not properly respected the privacy of you health information, you

are free to complain to me, or to the U.S. Department of Health and Human Services, Office 

for Civil Rights. I will not retaliate against you if you make a complaint. If you want to 

complain to me, send a written complaint to me at the address, fax or E-Mail shown at the 

beginning of this Notice. If you prefer, you can discuss your complaint in person or by

phone.



FOR MORE INFORMATION



If you want more information about our privacy practices, call the contact person at the

address or phone number shown at the beginning of this Notice.