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NeuroConnect Psychotherapy   



This notice describes how medical and psychological information about you may be used and disclosed, and how you can get access to this information.

We are required by federal and state law to maintain the privacy of your health information, and to provide you with a description of our privacy practices. This notice will tell you how your provider will use medical information here in this office, when and how it can be shared with other professionals and organizations, and how you can see it. If you have any questions, we will be happy to help you understand our procedures and your rights.

I. What Is Protected Health Information?
Protected health information (PHI) is information in your treatment record that identifies you (i.e. name, date of birth, etc.). Each time you visit me, information is collected about you and your health, and recorded in your health care records. PHI is likely to include information such as your personal history, reasons for coming to treatment, your diagnoses and treatment plan, progress notes for each session, records or reports from other providers or agencies who have treated or evaluated you, psychological test scores, information about medications you took or are taking, and billing and insurance information.


II. Privacy And The Laws About Privacy
We are required to tell you about privacy because of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA requires me to protect the privacy of your PHI, to tell you about your rights and my legal duties in regard to your PHI, and to tell you about our privacy practices. We are obligated to obey the rules described in the most current version of this notice.


III. Uses And Disclosures With Your Consent
We may use and disclose PHI for purposes of treatment, payment, and health care operations. “Use” applies to activities within my office that help to manage the services we provide. “Disclosure” applies to activities outside the office, such as releasing, transferring, or providing access to other individuals or organizations. “Consent” refers to your agreement to the policies described in this document, which you indicate through your signature on the “Acknowledgment of Receipt of Notice of Privacy Practices.”



We will use your medical information to provide you with psychological treatments or services such as individual, family, or group therapy; psychological or educational testing; treatment planning; or measuring the benefits of services provided. We may share your PHI with others who provide treatment to you, such as your physician, or if/when we refer you to other healthcare professionals. We may also receive PHI from other healthcare professionals involved in your care, which will go into your records here.


Payment. We may use your information to bill you, your insurance, or others, so that we can be paid for the treatments provided to you. We may contact your insurance company to find out what services your insurance plan covers. We may have to tell your insurance company about your diagnoses, the treatments you have received, treatment plan, and your progress in order to be reimbursed for my services.


Healthcare operations. We may use your PHI for activities related to the performance, operation, and maintenance of the practice, such as quality assessments, business-related matters such as audits and administrative services, and for case management or care coordination. For example, We may hire a billing service to submit bills to insurance companies. Under the law, providers of such services are called “business associates.” To protect your privacy, any business associates will agree to safeguard your information, and they will receive only the PHI required to do their job. We may also use and disclose PHI to schedule appointments with you or to provide you with appointment reminders.


IV. Uses And Disclosures That Require Your Authorization.
We may use and disclose your PHI for purposes outside of treatment, payment, and healthcare operations with your written authorization. An authorization is specific, written permission above and beyond general consent. When information is disclosed for purposes other than treatment, payment, and healthcare operations, such as consulting with a child’s teacher, We will obtain an authorization form from you before releasing the information. You may cancel your authorization in writing at any time. We would then stop using or disclosing your information for that purpose. Of course, We cannot take back any information already disclosed or used with your permission.


V. Uses And Disclosures That Do Not Require Your Consent Or Authorization
We may use or disclose your PHI without your consent or authorization under circumstances such as those described below. If any of these situations arise, We will attempt to discuss it with you before taking action, and will disclose only necessary information.

Abuse or neglect: If we have reasonable cause to believe that a child, elderly person, or other vulnerable adult has been abused, exploited, or neglected, we are required to report my suspicion to law enforcement and to the Department of Social and Health Services.

Legal proceedings: If you are involved in a lawsuit or legal proceeding, and we receive a subpoena, discovery request, or other lawful process, we may have to release PHI.

Law enforcement: We may be required to release information to law enforcement officials.

Government oversight: As a health care provider, we are subject to oversight by federal and state agencies. If a government agency makes a lawful request, we may be required to disclose PHI as part of audits, inspections, or investigations.

Veterans and military personnel: we may be required to disclose PHI of current or past members of the armed forces, security, or intelligence services to government authorities, or to benefit programs relating to eligibility and enrollment.

Worker’s compensation: we may be required to disclose PHI to workers’ compensation and disability programs to the extent necessary to comply with laws relating to programs that provide benefits for work-related injuries or illness.

Threat to safety: we may use or disclose PHI if we believe it is necessary to prevent a serious threat to you or to someone else.

Medical emergency: In the event of a medical emergency or involuntary commitment, we may disclose PHI to facilitate treatment.

Healthcare providers: As a result of state regulations adopted by the Washington State Department of
Health, we am required to report another healthcare provider in the event of a final determination of unprofessional conduct, a determination of risk to patient safety due to a mental or physical condition, or if we have actual knowledge of unprofessional conduct by another licensed provider. Note: If you yourself are a healthcare provider, and we believe that your behavior is a clear and present danger to your patients or clients, we are also required to report you.


VI. Your Rights Concerning Your Health Information
HIPAA provides you with the following rights regarding your clinical record and disclosures of your PHI. Requests must be made in writing.

Right to request restrictions: You have the right to ask me to limit the use and disclosure of your PHI. Although we am not required to agree to a restriction you request, if we do agree, we will honor the request except when it is against the law, in an emergency situation, or when the information is necessary to treat you.

Right to confidential communications: You have the right to ask me to 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 me to call you to schedule appointments at home, rather than at work, or to send mail to someplace other than your home address.

Right to inspect records: You have the right to look at the health information we have about you, such as your medical and billing records. You can get a copy of these records, but we may charge you for postage and a state-determined rate for copying. We may deny access to PHI under some circumstances. If we do so, we will explain any options you may have for a review of that decision.

Right to amend: If you believe that the information in your records is incorrect or missing something important, you can ask me to make additions to your records to correct the situation. This request must be made in writing, and include the reasons you want to make the changes. If we do not approve your request, we will tell you why, and explain any right you may have to file a written statement of disagreement.

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

Right to an accounting: You have the right to request an accounting of disclosures of PHI to which you did not consent or provide authorization. We are not required to account for disclosures of PHI for treatment, payment, or healthcare operations, or for which you provided consent or authorization.

VII. If You Have Questions Or Problems
If you need more information or have questions about the privacy practices described above, please speak to me. If you have concerns about how your PHI has been handled, or if you believe your privacy rights have been violated, please contact me immediately so we can address your concerns together with you. If this does not resolve your concerns, you have the right to file a complaint with the Secretary of the U.S. Department of Health and Human Services. we can provide you with the form for the complaint. Filing a complaint will not limit your care here, and we will not take any actions against you if you complain.
Complaints may be filed with:
Regional Manager, Health and Human Services Region X – Seattle (Alaska, Idaho, Oregon, Washington)
Office for Civil Rights
U.S. Department of Health and Human Services
2201 Sixth Avenue - M/S: RX-11
Seattle, WA 98121-1831
Voice Phone (206)615-2290 FAX (206)615-2297 TDD (206)615-2296


VIII. Effective Date, Restrictions, And Changes To Privacy Practices
The effective date of this notice is March 6th, 2020. We can reserve the right to change the terms of this notice. All changes will be consistent with state and federal law. The revised notice will be effective for all PHI that we maintain, including for PHI collected previously. We am not obligated to tell you when the notice changes, but will post the revised notice in the front office. You are entitled to request a paper copy of the current notice at any time.

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