Privacy Statement




Our practice is dedicated to maintaining the privacy of your personal health information (PHI) as part of providing professional care. We also are required by law to keep your information private. These laws are complicated, but we must give you this important information. This notice is posted in our waiting room. A copy of this document is also available from our front office staff. Please contact our Privacy Officer about any questions or problems you may have.

For Treatment

We use your medical information to provide you with psychological treatments or services. These might include individual, family, or group therapy, psychological, educational, or vocational testing, treatment planning, or measuring the benefits of our services.
We may share or disclose your PHI to others who provide treatment to you. We are likely to share your information with your personal physician. If you are being treated by a team, they can share some of your PHI with us so that the services you receive will be able to work together. If you receive treatment in the future from other professionals, we can also share your PHI with them. These are some examples so that you can see how we use and disclose your PHI for treatment.

For Payment

We may use your information to bill you, your insurance, or others so we can be paid for the treatments we provide to you. We may contact your insurance company to check on exactly what your insurance covers. We may have to tell them about your diagnoses, what treatments you have received, and the changes we expect in your conditions. We will need to tell them about when we have met, your progress, and other similar things.

Your health care operations

There are a few ways we may use or disclose your PHI for what are called health care operations. For example, we may use your PHI to see where we can make improvements in the care and services we provide. We may be required to supply some information to some government health agencies so they can study disorders and treatment and make plans for services that are needed. If we do, your name and personal information will be removed from what we send.

Other uses in healthcare

Appointment Reminders. We may use and disclose medical information to reschedule or remind you of appointments for treatment or other care. If you want us to call or write to you only at your home or your work or prefer some other way to reach you, we usually can arrange that. Just tell us.

Treatment Alternatives. We may use and disclose your PHI to tell you about or recommend possible treatment or alternatives that may be of help to you.

Other Benefits and Services. We may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.

Business Associates. There are some jobs we hire other businesses to do for us. In the law, they are called our Business Associates. Examples include a telephone answering service, software vendors and a bill collection agency. These business associates need to receive some of your PHI to do their jobs properly. To protect your privacy they have agreed in their contract with us to safeguard your information.


If we want to use your information for any purpose beside the TPO or those we described above we need your permission on an Authorization form. We don’t expect to need this very often.

If you do authorize us to use or disclose your PHI, you can revoke (cancel) that permission, in writing, at any time. After that time we will not use or disclose your information for the purposes that we agreed to. Of course, we cannot take back any information we have disclosed with your permission or that we had used in our office.

Of course we will keep you health information private, but there are some times when the law requires us to use or share it. For example:

  1. When there is a serious threat to your health and safety or the health and safety of another individual or the public. We will only share information with a person or organization which is able to help prevent or reduce the threat.
  2. Some lawsuits and legal or court proceedings.
  3. If a law enforcement official requires us to do so
  4. For Workers Compensation and similar benefit programs.
  5. When we receive information about abuse or neglect of a child, disabled adult or person over age 65.


  1. You can ask us to communicate with you about our health and related issues in a particular way or at a certain place which is more private for you. For example, you can ask us to call you at home and not at work, to schedule or cancel an appointment. We will try our best to do as you ask.
  2. You have the right to ask us to limit what we tell people involved in your care or the payment for your care, such as family members, and friends. While we don’t have to agree to your request, if we do agree, we will keep our agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you.
  3. You have the right to look at health information we have about you such as your medical or billing records. You can even get a copy of these records, but we may charge you. Contact our Privacy Officer to arrange how to see your records. See below.
  4. If you believe the information in your records in incorrect or missing important information, you can ask us to make some kinds of changes (called amending) to your health information. You have to make this request in writing and send it to our Privacy Officer. You must tell us the reasons you want to make the changes.
  5. Upon written request, you may obtain an accounting of certain disclosures of PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosure that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you $0.25 per page of the accounting statement.
  6. You have a right to a copy of this notice. If we change this NPP we will post the new version in our waiting area and you can get a copy of the NPP form from the Privacy Officer or front office staff.
  7. If you need more information or have question about the privacy practices described above, please contact the Privacy Officer. If you have a problem with how our PHI has been handled or if you believe your privacy rights have been violated, contact the Privacy Officer. You have the right to file a complaint with us and with the Secretary of the Federal Department of Health and Human Services. We promise that we will not in any way limit your care here or take any actions against you if you complain.

The effective date of this notice is April 22, 2003.