Notice of privacy practices (HIPAA):
THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. YOU MAY HAVE ADDITIONAL RIGHTS UNDER STATE AND LOCAL LAW. PLEASE SEEK LEGAL COUNSEL FROM AN ATTORNEY LICENSED IN YOUR STATE IF YOU HAVE QUESTIONS REGARDING YOUR RIGHTS TO HEALTH CARE INFORMATION.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on August 21, 2023.
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
Under the Health Insurance Portability and Accountability Act of 1996 (hereafter, “HIPAA”), you have certain rights
regarding the use and disclosure of your protected health information (hereafter, “PHI”).
I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health
information about you. I create a record of the care and services you receive from me. I need this record to provide you
with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care
generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose
health information about you. I also describe your rights to the health information I keep about you, and describe certain
obligations I have regarding the use and disclosure of your health information.
I am required by law to:
● Make sure that PHI that identifies you is kept private.
● Give you this notice of my legal duties and privacy practices with respect to health information.
● Follow the terms of the notice that is currently in effect.
● I can change the terms of this Notice, and such changes will apply to all the information I have about you. The
new Notice will be available upon request, in my office, and on my website.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or
disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be
listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment, Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who
have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information
without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care
operations. I may also disclose your PHI for the treatment activities of any health care provider. This too can be done
without your written authorization. For example, if a clinician were to consult with another licensed health care provider
about your condition, we would be permitted to use and disclose your PHI, which is otherwise confidential, in order to
assist the clinician in diagnosis and treatment of your health condition. I may also use your PHI for operations purposes,
including sending you appointment reminders, billing invoices and other documentation.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other
health care providers need access to the full record and/or full and complete information in order to provide quality care.
The word “treatment” includes, among other things, the coordination and management of health care providers with a
third party, consultations between health care providers and referrals of a patient for health care from one health care
provider to another.
Business Associates: There are some tasks I may hire other businesses to do for me. Examples include a copy service
used to make copies of your health records, a biller for insurance, and a bookkeeper. These business associates need to
receive some of your health information to do their jobs properly. To protect your privacy, they agree in their contract
with me to safeguard your information. I may use your information to bill you, your insurance, or others so I can be paid
for the treatments I provide to you. I may contact your insurance company to check on exactly what your insurance covers.
I may have to tell them about your diagnoses, what treatments you have received, and the changes I expect in your conditions.
I will need to tell them about when we met, your progress, and other similar things.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or
administrative order. I may also disclose health information about you or your minor child(ren) in response to a subpoena,
discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to
tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use
or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising mental health practitioners to help them improve their skills in group,
joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of the Department of Health and Human Services (HHS) to investigate my
compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy
notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
2. Marketing Purposes. I will not use or disclose your PHI for marketing purposes without your prior written consent.
For example, if I request a review from you and plan to share the review publically online or elsewhere to advertise
my services or my practice, I will provide you with a release form and HIPAA authorization. The HIPAA
authorization is required in the instance that your review contains PHI (i.e., your name, the date of the service you
received, the kind of treatment you are seeking or other personal health details). Because you may not realize
which information you provide is considered “PHI,” I will send you a HIPAA authorization and request your
signature regardless of the content of your review. Once you complete the HIPAA authorization, I will have the
legal right to use your review for advertising and marketing purposes, even if it contains PHI. You may withdraw
this consent at any time by submitting a written request to me via the email address I keep on file or via certified
mail to my address. Once I have received your written withdrawal of consent, I will remove your review from my
website and from any other places where I have posted it. I cannot guarantee that others who may have copied
your review from my website or from other locations will also remove the review. This is a risk that I want you to
be aware of, should you give me permission to post your review.
3. Sale of PHI. I will not sell your PHI.
IV. USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following
reasons. I have to meet certain legal conditions before I can share your information for these purposes:
1. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to
remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about
treatment alternatives, or other health care services or benefits that I offer.
2. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the
relevant requirements of such law.
3. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or
reducing a serious threat to anyone’s health or safety.
4. For health oversight activities, including audits and investigations.
5. For judicial and administrative proceedings, including responding to a court or administrative order or subpoena,
although my preference is to obtain an Authorization from you before doing so if I am so allowed by the court or
administrative officials.
6. For law enforcement purposes, including reporting crimes occurring on my premises.
7. To coroners or medical examiners, when such individuals are performing duties authorized by law.
8. For research purposes, including studying and comparing the mental health of patients who received one form of
therapy versus those who received another form of therapy for the same condition.
9. Specialized government functions, including, ensuring the proper execution of military missions; protecting the
President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the
safety of those working within or housed in correctional institutions.
10. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may
provide your PHI in order to comply with workers’ compensation laws.
11. For organ and tissue donation requests.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others: You have the right and choice to tell me that I may provide your PHI to a family
member, friend, or other person whom you indicate is involved in your care or the payment for your health care, or to share
you information in a disaster relief situation. The opportunity to consent may be obtained retroactively in emergency
situations to mitigate a serious and immediate threat to health or safety or if you are unconscious.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or
disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your
request, and I may say “no” if I believe it would affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request
restrictions on the disclosure of your PHI to health plans for payment or health care operations purposes if the
PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for
example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than in limited circumstances, you have the right to get an
electronic or paper copy of your medical record and other information that I have about you. Ask us how to do
this. I will provide you with a copy of your record, or if you agree, a summary of it, within 30 days of receiving your
written request. I may charge a reasonable cost based fee for doing so. If I determine that reviewing your records
may cause substantial and identifiable harm to you or others or would have a detrimental effect on your treatment,
on our professional relationship, or on your relationship with parents, guardians, spouses, or children, I may deny
access to your records.
5. The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I
have disclosed your PHI for purposes other than treatment, payment, or health care operations, ans other
disclosures (such as any you ask me to make). Ask me how to do this. I will respond to your request for an
accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures
made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you
make more than one request in the same year, I will charge you a reasonable cost based fee for each additional
request.
6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of
important information is missing from your PHI, you have the right to request that I correct the existing
information or add the missing information. I may say “no” to your request, but I will tell you why in writing within
60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice,
and you have the right to get a copy of this notice by email. And, even if you have agreed to receive this Notice via
email, you also have the right to request a paper copy of it.
8. The Right to Choose Someone to Act For You. If you have given someone medical power of attorney or if
someone is your legal guardian, that person can make choices about your health information.
9. The Right to Revoke an Authorization.
10. The Right to Opt out of Communications and Fundraising from our Organization.
11. The Right to File a Complaint. You can file a complaint if you feel I have violated your rights by contacting me
using the information on page one or by filing a complaint with the HHS Office for Civil Rights located at 200
Independence Avenue, S.W., Washington D.C. 20201, calling HHS at (877) 696-6775, or by visiting
www.hhs.gov/ocr/privacy/hipaa/complaints. I will not retaliate against you for filing a complaint.
VII. CHANGES TO THIS NOTICE
I can change the terms of this Notice, and such changes will apply to all the information I have about you. The new Notice
will be available upon request, in my office and on my website.
- Visit our website
at http://www.wanderingtidescounseling.com , or any website of ours that links to this privacy notice
- Engage with us in other related ways, including any sales, marketing, or events
email addresses
names
phone numbers
contact preferences
personal history
health data
health insurance
financial data
- Log and Usage Data. Log and usage data is service-related, diagnostic, usage, and performance information our servers automatically collect when you access or use our Services and which we record in log files. Depending on how you interact with us, this log data may include your IP address, device information, browser type, and settings and information about your activity in the Services (such as the date/time stamps associated with your usage, pages and files viewed, searches, and other actions you take such as which features you use), device event information (such as system activity, error reports (sometimes called
"crash dumps" ), and hardware settings).
- Device Data. We collect device data such as information about your computer, phone, tablet, or other device you use to access the Services. Depending on the device used, this device data may include information such as your IP address (or proxy server), device and application identification numbers, location, browser type, hardware model, Internet service provider and/or mobile carrier, operating system, and system configuration information.
- Location Data. We collect location data such as information about your device's location, which can be either precise or imprecise. How much information we collect depends on the type and settings of the device you use to access the Services. For example, we may use GPS and other technologies to collect geolocation data that tells us your current location (based on your IP address). You can opt out of allowing us to collect this information either by refusing access to the information or by disabling your Location setting on your device. However, if you choose to opt out, you may not be able to use certain aspects of the Services.
- To deliver and facilitate delivery of services to the user. We may process your information to provide you with the requested service.
- To respond to user inquiries/offer support to users. We may process your information to respond to your inquiries and solve any potential issues you might have with the requested service.
- To enable user-to-user communications. We may process your information if you choose to use any of our offerings that allow for communication with another user.
- To evaluate and improve our Services, products, marketing, and your experience. We may process your information when we believe it is necessary to identify usage trends, determine the effectiveness of our promotional campaigns, and to evaluate and improve our Services, products, marketing, and your experience.
- To identify usage trends. We may process information about how you use our Services to better understand how they are being used so we can improve them.
- To comply with our legal obligations. We may process your information to comply with our legal obligations, respond to legal requests, and exercise, establish, or defend our legal rights.
- Business Transfers. We may share or transfer your information in connection with, or during negotiations of, any merger, sale of company assets, financing, or acquisition of all or a portion of our business to another company.
- Affiliates. We may share your information with our affiliates, in which case we will require those affiliates to
honor this privacy notice. Affiliates include our parent company and any subsidiaries, joint venture partners, or other companies that we control or that are under common control with us.
- Business Partners. We may share your information with our business partners to offer you certain products, services, or promotions.