Print, fill out by hand, and bring to your appointment.

HIPAA NOTICE OF PRIVACY PRACTICES

IT IS MY LEGAL AND ETHICAL DUTY TO KEEP ALL INFORMATION YOU GIVE ME CONFIDENTIAL UNLESS YOU GIVE ME PRIOR WRITTEN PERMISSION.

THERE ARE IMPORTANT EXCEPTIONS TO CONFIDENTIALITY:

  1. If you are likely to cause serious harm to yourself or another vulnerable person (someone who cannot protect him or herself) and I decide that the only way to prevent the harm is to get outside help. Child and vulnerable adult abuse and neglect reporting laws require that I report an ongoing threat of physical or emotional harm to a minor child or abuse, neglect, or financial exploitation of vulnerable, dependent, or elderly adults.
  2. To obtain payment for treatment from your insurance company. This is usually limited to giving brief identifying information, diagnosis, and types and dates of service. Some companies also require periodic, brief disclosure of treatment goals and your progress in treatment.
  3. Medical emergency in which you are unable to speak or get help yourself.
  4. Court orders: I will only respond to an official court order, subpoena, or warrant signed by a judge. I will not respond to any other officer of the law or court requesting information without your written permission. I will attempt never to respond without your permission unless I believe you are in serious danger of harming yourself or someone else (in which case, I am required to report).
  5. For investigation of professionals. I may be required to disclose confidential information to assist in the investigation of a health care provider who may have committed malpractice or a crime.

Other Uses & Disclosures Require Your Prior Written Authorization. For you to obtain Worker’s Compensation or disability benefits, at your request and with your written permission, I will disclose confidential information for disability applications or reviews.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

  1. The Right to See & Get Copies of Your Health Information. I will respond within 30 days of receiving your written request. If I believe I must deny your request, I will give you, in writing, the reasons for the denial. You have the right to have my denial reviewed.
  2. The Right to Get a List of the Disclosures I Have Made, not including uses or disclosures to which you have already consented. I am not legally obligated to list disclosures made for national security purposes or law enforcement personnel.
  3. The Right to Amend Your Health Information. If you believe there is an error or important omission in your health records, you may ask that we correct the record or add your response within 60 days. Your request and the reason for it must be made in writing.

HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES

If you believe I have violated your privacy rights or if you object to a decision I have made about access to your information, you are entitled to send a written complaint to the Secretary of the Department of Health and Humans Services at 200 Independence Ave, SW Washington, DC 20201.

You may request a copy of this Notice from me.

I acknowledge receipt of this notice:

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