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By law, we are required to provide you with our Notice of Privacy Practices (NPP).  This Notice describes how your medical information may be used and disclosed by us.  It also tells you how you can obtain access to this information.


Your Rights

You have the right to:

  • Inspect and copy your information;

  • Request corrections to your information;

  • Request an amendment to the PHI maintained as part of the client’s PHI

  • Write a statement of disagreement if a requested amendment is denied

  • Request confidential communication;

  • Request that your information be restricted;

  • A report of disclosures of your information;

  • Get a copy of this privacy notice;

  • File a complaint if you believe your privacy rights have been violated;


Our Uses and Disclosures

We may use and share your information as we:

  • Treat you. Example, we use health information about you to manage your treatment and services

  • Bill for your services. Example: we give information about you to your health insurance plan so it will pay for your services.

  • Help with public health and safety issues.  Example, we can report suspected abuse, neglect, suicidal ideation or homicidal ideation.

  • Comply with the law.  Example, we will share information about you if state or federal law require it.

  • Respond to lawsuits and legal action.  Example: we can share health information about you in response to a court or administrative order, or in response to a subpoena.


Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.

  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

  • We must follow the duties and privacy practices described in this notice and give you a copy of it.

  • We will not use or share your information other than as described here unless you tell us we can in writing.  If you tell us we can, you may change your mind at any time.  Let us know in writing if you change your mind.

  • We must agree to restrict disclosures to health plans if the PHI pertains to a health care item or service for which we have been paid in full.

  • We are not required to agree to other requested restrictions.


Changes to the Terms of this Notice

We can change the terms of this notice and the changes will apply to all information, we have about you.  The new notice will be available upon request, in our office and on our website.


Filing a Complaint

You can complain if you feel we have violated your rights by contacting us.  You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by calling 1-877-696-6775, or visiting  We will not retaliate against you for filing a complaint.



Effective Date of this Notice:­­­­­­­­­­­­­­­­­­­­­­______________________________________________________


Contact Person:_________________________________________________________________


Phone Number:_________________________________________________________________



Acknowledgement of Notice of Privacy Practices

“I hereby acknowledge that I have received a copy of this practice’s NOTICE OF PRIVACY PRACTICES.  I understand that if I have questions or complaints regarding my privacy rights that I may contact the person listed above.  I further understand that the practice will offer me updates to the NOTICE OF PRIVACY PRACTICES should it be amended, modified, or changed in any way”.


Client or Guardian’s Name:________________________________________________________

                                                                        (please print)


Client or Guardian’s Signature:_____________________________________________________







Confidentiality - Participation in therapy is confidential. Therapist will not acknowledge a person's participation nor share any information without written consent with the exceptions of intention of imminent harm (to self or other) or child abuse. At first appointment, client signs a consent to treatment, which includes consent to bill their insurance if they want to use it, and consent for my Billing Service to process the claims.


Release of Medical Records

Medical records or information will be released with an appropriate, signed release of information, which will be kept in the file.

An urgent verbal request to release information from the client will be noted in the chart, if the information needs to be released before the client is seen to sign a paper release, then a form will be signed and filed the next time the client is seen.


Employees/ Contractors

There are no employees who have access to the records.

The bookkeeper/date entry person has access only to billing records and will follow HIPPA procedures for confidentiality and privacy.  Information will be transferred by computer disk.


Offsite Management

Records more than 5 years old may be stored offsite in a locked file cabinet.  Records more than 10 years old may be shredded, keeping a list of names, birthdates and treatment beginning and ending dates.


Records management

Open cases are kept in one drawer.  Closed cases in another.  File is kept locked.  Filed alphabetically.


Intake information forms are filed in the front, then Office Policies, Counselor disclosure and Releases of information.  Chart notes and authorizations are filed by date, latest information in the back.


Special situations, risk factors and plans are documented in the chart, flagged in the entry title.  Clients who express suicidal or other harm ideation are contracted for safety, plans to not be alone or have support system.  Involuntary treatment or the hospital will be contacted for those unable to contract for safety.

Reports of child abuse with enough identifying information (victim, perpetrator, contact information) are reported to CPS.


Allergies and adverse reactions are not prominently displayed, as this office does not prescribe.


Practitioner writes all documentation.

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