You are using an outdated browser. For a faster, safer browsing experience, upgrade for free today.

Notice of Mental Health Privacy Practices

General information
All information describing your mental health treatment and related health care services is personal, and I am committed to protecting the privacy of the personal and mental health information you disclose to me. I am required by law to maintain the confidentiality of information that identifies you and the care you receive. When I disclose information to other persons and companies to perform services for you, I require them to protect your privacy, too. I must also provide certain protections for information related to any medical diagnoses and treatment, including HIV/AIDs, and information about alcohol and other substance abuse. I am required by law to give you this Notice about my privacy practices, your rights, and my legal responsibilities. (Click on the sections below to read more.)   
  • For TREATMENT: For example, I may give information about your psychological condition to other health care providers to facilitate your treatment, referrals, or consultations.
  • For PAYMENT: For example, I may contact your insurer to verify what benefits you are eligible for, to obtain prior authorization, and to receive payment from your insurance carrier.
  • For APPOINTMENTS AND SERVICES: To remind you of an appointment or tell you about treatment alternatives and health related benefits or services.
  • To INDIVIDUALS INVOLVED IN YOUR CARE: Such as your parents, if you are a minor, or your conservator.
  • WITH YOUR WRITTEN AUTHORIZATION: I may use or disclose mental health information for purposes not described in this Notice, but only with your written authorization.
  • As REQUIRED BY LAW: when required or authorized by other laws, such as the reporting of child abuse, elder abuse or dependent adult abuse.
  • For HEALTH OVERSIGHT ACTIVITIES: to governmental, licensing, auditing, and accrediting agencies as authorized or required by law including audits; civil, administrative or criminal investigations; licensure or disciplinary actions; and monitoring of compliance with law.
  • In JUDICIAL PROCEEDINGS: in response to court/administrative orders, subpoenas, discovery requests or other legal process. To PUBLIC HEALTH AUTHORITIES: to prevent or control communicable disease, injury or disability, or ensure the safety of drugs and medical devices.
  • To LAW ENFORCEMENT: for, example, to assist in an involuntary hospitalization process.
  • For RESEARCH PURPOSES: subject to a special review process, and the confidentiality requirements of state and federal law.
  • To PREVENT A SERIOUS THREAT TO HEALTH OR SAFETY: of an individual. I may notify the person, tell someone who could prevent the harm, or tell law enforcement officials.
  • To PROTECT CERTAIN ELECTIVE OFFICERS: including the President, by notifying law enforcement officers of potential harm.
  1. To Receive a Copy of this Notice when you obtain care.
  2. To Request Restrictions. You have the right to request a restriction or limitation on the mental health information I disclose about you for treatment, payment or health care operations. You must put your request in writing. I am not required to agree with your request. If I do agree with the request, I will comply with your request except to the extent that disclosure has already occurred or if you are in need of emergency treatment and the information is needed to provide the emergency treatment.
  3. To Inspect and Request a Copy of your Mental Health Record except in limited circumstances. A fee will be charged to copy your record. You must put your request for a copy of your records in writing. If you are denied access to your mental health record for certain reasons, I will tell you why and what your rights are to challenge that denial.
  4. To Request an Amendment and/or Addendum to your Mental Health Record. If you believe that information is incorrect or incomplete, you may ask me to amend the information or add an addendum (addition to the record) of no longer than 250 words for each inaccuracy. Your request for amendment and/or addendum must be in writing and give a reason for the request. I may deny your request for an amendment if the information was not created by me, is not a part of the information which you would be permitted to inspect and copy, or if the information is already accurate and complete. Even if I accept your request, I do not delete any information already in your records.
  5. To Receive An Accounting of Certain Disclosures I have made of your mental health information. You must put your request for an accounting in writing.
  6. To Request That I Contact You By Alternate Means (e.g., fax versus mail) or at alternate locations. Your request must be in writing, and I must honor reasonable requests.
I reserve the right to change this Notice. I reserve the right to make the revised or changed Notice effective for information I already have about you as well as any information I receive in the future.