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

your care.

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

appropriate matter.

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

of others.

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.

Client Rights:

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 costbased 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, costbased 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.

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