This notice describes how information about you may be used and disclosed and how you can get access to this information.

Health professionals are required by law to maintain the privacy of your health information and to provide you with notice of our legal duties and privacy practices with respect to your information. This Notice of Privacy Practices describes how we may use and disclose your personal information to carry out treatment, bill insurance companies for payment and for other purposes that are permitted or required by law.

It also describes your rights to access and control your personal information. "Personal information" is information about you, including demographic information that may identify you and that relates to your past, present or future physical or mental health or condition and/or related services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time, responding to the changing state and federal mandates. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling our office and requesting a copy to be sent to you in the mail or asking for one at the time of your next appointment.

1. How We May Use or Disclose your Personal Information

Information about you is stored in a chart and/or a computer. This is your record. The record is the property of the health professional, but the information in the record belongs to you. We protect the privacy of your personal information. The law permits us to disclose your information for the following purposes.

Uses and Disclosures of Personal Information based on your Written Consent

Your personal information (Name, Date of Birth, Health Insurance Identification #, Diagnosis, Dates of Service) is used in billing insurance companies for payment.

Your personal information is used as well in providing, coordinating or managing your treatment and any related services. This includes the coordination or management of your treatment with anyone else you give permission to have access to your records. For example, we would disclose your personal information to your health insurance provider that pays for service or to a physician from whom you may have been referred.

Your personal information will be used as needed to obtain payment for your services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the services we recommend for you such as making a determination of eligibility for benefits, reviewing services provided to you and undertaking utilization review activities.

Permitted and Required Uses and Disclosures that may be made without your consent, Authorization or Opportunity to Object

We may use or disclose your personal information in the following situations without your consent or authorization. These situations include:

  • Pursuant to court order or subpoena
  • Medical personnel in an emergency
  • Suspected incidences of child abuse or neglect
  • To report crime (or threat of crime) on premises or in emergencies

2. Your Rights

Following is a statement of your rights with respect to your personal information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your personal information. This means you may inspect and obtain a copy of personal information about you that is contained in a designated record set for as long as we maintain the personal information. A "designated record set" contains program and billing record and any other records used in making decisions about you.

Under federal law, however, you may not inspect or copy the following records:

  • Psychotherapy notes
  • Information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and personal health information that is subject to law that prohibits access to personal health information

You have the right to request a restriction of your personal information.This means that you may ask us not to disclose any part of your personal information for the purposes of treatment, payment or operations. Your request must state the specific restriction and to whom you want the restriction to apply.

We do not have to agree to a requested restriction, but will consider your request. If we agree to the requested restriction, we may not use or disclose your personal information in violation of that restriction unless it is needed to provide emergency treatment.

You have the right to request confidential communication from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition the accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.

You have the right to amend your personal information. This means you may request an amendment of personal information about you in a chart as long as we maintain this information. In certain circumstances, we may deny your request for an amendment. f we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of the rebuttal.

You have a right to receive an accounting of certain disclosures we have made, if any, of your personal information. This right applies to disclosures for purposes other than treatment, payment or program operations, as described in this Notice of Privacy Practices. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a short time frame. The right to receive this information is subject to certain expectations, restrictions and limitations.

You have the right to obtain a paper copy of this notice from us, upon request.

3. Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us to handle your concerns. We will not retaliate against you for filing a complaint.

If you are not satisfied with the manner in which your complaint was handled, you may submit a formal complaint to:

Department of Health and Human Services Office of Civil Rights Hubert H. Humphrey Bldg. 200 Independence Avenue, S.W. Room 509F HHH Building Washington, DC 20201

You may also address your complaint to one of the regional Offices for Civil Rights. A list of these offices can be found online at