NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS
I am required by federal and state law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices.
Use and Disclosure of Health Information
Unless you give me written authorization, I cannot use or disclose your
health information for any reasons except those described below . If you give me an
authorization, you may revoke it in writing at any time. Your revocation will not
affect any use or disclosures permitted by your authorization while it was in effect.
1. In the event of your incapacity or emergency circumstances, I will disclose only
that health information which, in my professional judgment, is directly relevant to
2. I may use or disclose your health information when I am required to do so by law,
for example, when ordered to do so by a court having jurisdiction over an
3. I may disclose your health information to appropriate authorities if I reasonably
believe that you are a possible victim of abuse, neglect or domestic violence or the
possible victim of other crimes. I may disclose your health information to the extent
necessary to avert a serious threat to your health or safety or to the health or safety
4. I may disclose to military authorities the health information of Armed Forces
personnel under certain circumstances involving national security. I may disclose to
authorized federal officials health information required for lawful intelligence,
counterintelligence, and other national security activities.
5. I may disclose health information to correctional institutions or law enforcement
officials who have lawful jurisdiction over protected health information.
You have the right to inspect or obtain copies of your health information,
except for therapist's notes and certain other limited exceptions. You should make
your request in writing to me. You may request that I provide copies in a format
other than photocopies. I will use the format you request unless I cannot practically
do so. I will charge you a reasonable cost‐based fee for providing your health
information in the chosen format. If you prefer, I will prepare a summary or an
explanation of your health information, and will charge a reasonable fee for this
service, based on the preparation time involved.
If access to your health information is denied, you or your personal
representative will be provided with a written denial, setting forth the basis for the
denial, a description of how you may appeal the decision and a description of how
you may complain to the secretary of the U.S. Department of Health and Human
You have the right to receive a list of instances in which I have disclosed your
health information over the last years, but not before 2012. If you
request this accounting more than once in a 12 month period, I may charge you a
reasonable, cost‐based fee for responding to these additional requests.
You have the right to request that I place additional restrictions on my use or
disclosure of your health information. I am not required to agree to these additional
restrictions, but if I do, I will abide by our agreement (except in an emergency).
You have the right to request that I communicate with you about your health
information by alternative means or to alternative locations. You must make your
request in writing, and your request must specify the alternative means or location,
while providing satisfactory explanation of how payments will be handled under the
alternative means or location you request.
You have the right to request that I amend your health information. Your
request must be in writing, and it must explain why the information should be
amended. I may deny your request under certain circumstances. I have 60 days
after the request is made to act on the request. A single 30 day extension is
permissible if I am unable to comply by the deadline. If the request is denied in
whole or in part, I will provide you with a written denial and explanation. You or
your personal representative may then submit a written statement disagreeing with
the denial and have the statement included with any future disclosure of your
Protected Health Information.
Questions and Complaints:
If you want more information about my privacy practices or have questions or
concerns, please speak with me about this. If you are concerned that I may have
violated your privacy rights or any other of the other client rights described above,
you may complain to me directly. You may also submit a written complaint to the
U.S. Department of Health and Human Services; I will provide you with the address
for such a complaint upon request. I support your right to privacy, and will not
retaliate in any way if you choose to file a complaint with me or with the U.S.
Department of Health and Human Services.
NIDIA PONCE, LCSW
I am truly enthusiastic and committed about helping people create the change they want to see in their life!