Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.

Record Keeping Practices: Standard practice requires me to keep a record of your treatment. This includes a general description of your emotional functioning, a diagnosis (required if you request a receipt of services to give to your insurance), goals of treatment, symptoms, your progress, and homework assignments if given. This record of treatment is your Protected Healthcare Information, or PHI.

Uses and Disclosures of your PHI: I may use or disclose your PHI to coordinate or manage your treatment. An example of treatment would be when I consult with another healthcare provider or therapist. I will disclose your PHI if you request a receipt of services for a third party, such as reimbursement for your health insurance provider. I may disclose your PHI during activities that relate to the performance and operation of my practice. Examples include but are not limited to, quality assessments, case management, legal purposes, audits, administrative services and appointment reminders.

Use and Disclosures that DO NOT REQUIRE your Authorization: I may use or disclose your PHI to the extent that the use or disclosure is Required by Law, made in compliance with the law and limited to the relevant requirements of the law. Examples include public health reports, law enforcement reports, abuse and neglect reports and reports to coroners and medical examiner in connection with death. I also must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.

• I may disclose your PHI to a Health Oversight agency for activities authorized by law, such as my professional licensure. Oversight agencies also include government agencies and organizations that provide financial assistance to me, such as third party payers.

• If I have a reasonable cause to believe that a child has suffered abuse or neglect. I am required by law to report it to the proper law enforcement agencies.

• If I have reasonable cause to believe that abandonment, sexual or physical abuse, financial exploitation or neglect of a vulnerable adult has occurred, I must report the abuse to the Washington Department of Social and Health Services.

• In the instance that you or someone else is in imminent danger of harm of self or others, I may disclose your PHI for the purposes of safety. I may also disclose your PHI to law enforcement officials if you have committed a crime on my premises or against me.

• I may disclose your PHI to my Business Associates that I contract with for therapy consultation, legal services, and other healthcare professionals associated with your treatment. My contract with them requires them to safeguard the privacy of your information.

• I will disclose your PHI if a Court of Competent Jurisdiction issues an appropriate order. I will disclose your PHI if you and I have been notified in writing at least 14 days in advance of a subpoena or other legal demand, and no protective order has been obtained and I have satisfactory assurances that you have received notice of opportunity to have limited or quashed the discover demand.

Uses and Disclosures of your PHI with your Written Authorization: I will make other uses and disclosures of your PHI only when your appropriate authorization is obtained. An authorization is written permission that permits specific disclosures. You may revoke this authorization in writing at any time, unless I have taken reliance on the authorization of the use or disclosure you permitted.

Your Rights Regarding your PHI: You have the right to inspect and copy your PHI, for as long as I maintain it. I have 30 days to comply with your request, and may charge you a fee for these copies.

• You have the right to ask that I amend your record if you feel that the PHI is incorrect or incomplete. I am not required to amend it. You have the right to file a statement of disagreement with me, to which I am allowed to prepare a rebuttal and it will go in your file.

• You have the right to request the required accounting of disclosures that I make regarding your PHI. This documents any non-routine disclosures made for purposes other than your treatment, as well as disclosures made pertaining to your treatment for purposes of care.

• You have the right to request a restriction or limitation of the use of your PHI for treatment, payment, or operations of my practice. I am not required to agree to your request. In instances where I believe it is in the best interest of care, I will not honor your request.

• You have the right to request confidential communication with me. An example of this might be to send your mail to another address or not call you at home. I will accommodate reasonable requests and will not ask why you are making the requests.

• You have the right to have a paper copy of this notice.

If you believe that I have violated your privacy rights, you have the right to file a complaint in writing with me and/or the Secretary of Health and Human Services. I will not retaliate against you for filing a complaint.

Therapist Duties: This notice describes your rights regarding how you may gain access to and control your PHI and how I may use and disclose it. I am required by law to abide by the terms of this document and reserve the right to change the terms at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain, whether or not you are still in treatment with me. You may request a copy of my revised Notice of Privacy Practices at your appointment time or by leaving a request on my voicemail to receive a copy through the mail.

Crisis: I am not equipped to handle 24 hour crisis intervention. If you feel that you are experiencing a life threatening emergency please contact 911. Or, if you feel that you are experiencing an emotional mental health crisis, please contact the King County 24 hours Crisis Line for immediate assistance: 866.427.4747

Privacy Officer: I, Angelina Thomson, am my own privacy officer. If you have any questions about this document, please contact me.