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This document contains summary information

about the Health Insurance Portability and

Accountability Act of 1996 (HIPAA), the federal

law that provides privacy protections and

patient rights with regard to the use and

disclosure of your Protected Health Information

(PHI). HIPAA requires that I provide you with a

Notice of Privacy Practices for use and

disclosure of PHI for treatment, payment, and

healthcare operations. This notice explains

HIPAA and its application to your personal

health information in greater detail.

The law requires that I obtain your signature at

the end of your first session acknowledging

that I’ve provided you with this information.

Please read the sections below that explain

your privacy rights under HIPAA. If you have

any questions or concerns about your rights or

privacy, please speak to me about them at that


These two sections explain your rights under


Your Right to Privacy. Federal laws

governing how I use information about

your health and healthcare and

circumstances under which I may or am

required to disclose it.

Your Rights Regarding Your Healthcare

Information. Information from your files

that I’m required under federal law to

share with you; your right to amend

information in your health records; your

right to file a complaint if you feel your

privacy rights have been violated.

Your Right to Privacy

I will use the information about your health

(obtained from you or your other healthcare

providers) mainly to provide you with treatment.

I will also use it for business activities called

healthcare operations. This includes providing

you with a monthly billing statement of

sessions attended, session payments you have

made, a diagnosis / diagnoses, and type of

treatment sessions provided. I will not be

sending the billing statement to any insurance

companies (unless you make a special request

and sign a form authorizing me to do so). This

gives you control over the distribution of your

own healthcare transmission to your insurer.

If you or I want to disclose (send, share, or

release) your healthcare information for any

other purpose, I will discuss it with you and ask

that you sign an authorization form to allow

this. I cannot disclose this information without

your written permission.

Exceptions to my legal / professional obligation

to keep your healthcare information private:

When there is a serious threat to your

health or safety or to the health or

safety of another individual or the

public. (In this case, I would share your

information with a person or organization

that might be able to prevent or reduce

these threats.)

Some lawsuits and / or court


If a law enforcement official requires me

to do so.

For Workers’ Compensation and similar

benefit programs.

There are some other rare-exception

situations in which I may disclose

information without your permission:

situations in which your records might

be needed to investigate a crime;

situations in which your records are

requested by public health officials for

the investigation of diseases or injuries;

situations in which you are being

investigated by government or military

officials; situations after your death.

Your Rights Regarding Your Healthcare


You can request that I communicate

with you about your health and related

issues in a particular way or at a

certain place that is more private for

you. For example, you can ask that I

call you at home and not at work to

schedule or cancel an appointment. I

will do my best to do as you ask.

You have the right to limit what I tell

people involved in your care or people

involved in paying for your care, such

as family members and friends.

You have the right to look at the health

information I have about you, such as

your medical and billing records. You

may even request a copy of these

records, but I may charge you for

administrative time and copying. Please

speak to me directly to make a request

to look at your healthcare information.

You’re entitled to view the following

information: the modalities and

frequency of treatment sessions I have

provided for you; the results of clinical

tests, self-report forms, or symptommonitoring

sheets in your chart; a

written summary (written by me) of your

diagnosis, functional status, treatment

plan, symptoms, prognosis, and

progress to date.

The only exception to your automatic

right to review information in your

medical chart is viewing psychotherapy

notes I write. There are specific laws

governing psychotherapy session

notes, because these notes are

intended to assist the psychotherapist

only and have the potential of being

misinterpreted by others. If you would

still like to view the psychotherapy

notes, please speak with me about this.

I will review with you the pros and cons

of this, relevant to your treatment needs

and situation.

You have the right to accurate

information in your health records. If

you believe my records contain

incorrect or missing information, you

have the right to ask me to make

amendments to your records. Please

make this request in writing, indicating

the reason you want to make these

changes, and give the written request to

me to place in your medical chart.

You have the right to file a complaint if

you believe your privacy rights have

been violated. You can file a complaint

with me and with the Secretary of the

Department of Health and Human

Services. All complaints must be in

writing. Filing a complaint will not

change the healthcare I provide you.

Additional Reading Regarding Healthcare

Information Privacy

For further information about HIPAA and your

right to privacy regarding healthcare

information, visit the U.S. Department of

Health and Human Services website


In addition to the information in the above

sections, you may have other rights granted to

you by the laws of the State of New York, and

these may be different than the federal laws.

For further information on the New York state

law protecting patient rights, go to the NYS

Department of Health website


For further information about your rights as a

psychotherapy patient, visit the American

Psychological Association website