Effective Date: TBD

Privacy Contact:
Michelle Granden, PhD, LMHCA
(425) 780-6555
michelle@grandenpsychotherapy.com

Your Information. Your Rights. My Responsibilities.

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

YOUR RIGHTS

You have the right to:

• Get a copy of your paper or electronic medical record

• Correct your paper or electronic medical record

• Request confidential communication

• Ask me to limit the information I share

• Get a list of those with whom I've shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

YOUR CHOICES

You have some choices in the way that I use and share information as I:

• Tell family and friends about your condition

• Provide disaster relief

• Provide mental health care

MY USES AND DISCLOSURES

I may use and share your information as I:

• Treat you

• Run my practice

• Bill for your services

• Help with public health and safety issues

• Do research

• Comply with the law

• Respond to organ and tissue donation requests

• Work with a medical examiner or funeral director

• Address workers’ compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions

YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information I have about you. Ask me how to do this.

• I will provide a copy or a summary of your health information, usually within 30 days of your request. Washington law may require a shorter response time; in practice I aim to respond within 15 working days. I may charge a reasonable, cost-based fee.

Ask me to correct your medical record

• You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this.

• I may say "no" to your request, but I'll tell you why in writing within 60 days.

Request confidential communications

• You can ask me to contact you in a specific way (for example, at home, at work, by cell phone, or by email) or to send mail to a different address.

• I will say "yes" to all reasonable requests.

Ask me to limit what I use or share

• You can ask me not to use or share certain health information for treatment, payment, or my operations. I am not required to agree to your request, and I may say "no," for example, if it could affect your care. If I agree to your request, I may still share this information in the event that you need emergency treatment.

• If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will say "yes" unless a law requires me to share that information.

Get a list of those with whom I've shared information

• You can ask for a list (accounting) of the times I've shared your health information for six years prior to the date you ask, who I shared it with, and why.

• I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make). I’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.

Choose someone to act for you

• If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• I will make sure the person has this authority and can act for you before I take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel I have violated your rights by contacting me using the information at the beginning of this notice.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting HHS Office for Civil Rights — Filing a Health Information Privacy Complaint.

• I will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell me your choices about what I share. If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions.

In these cases, you have both the right and choice to tell me to:

• Share information with your family, close friends, or others involved in your care or payment for your care

• Share information in a disaster relief situation

If you are not able to tell me your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety.

Mental health care

Washington law provides additional confidentiality protections for information and records related to mental health services. I will protect your mental health information in accordance with Washington law and will not disclose it without your written authorization unless the disclosure is permitted or required by applicable law.

Marketing purposes, raising funds, and sale of your information

I never market, fundraise, or sell personal information.

Psychotherapy notes

I may maintain psychotherapy notes separately from your clinical record. Most uses and disclosures of psychotherapy notes require your specific written authorization. A general authorization for release of your clinical records does not authorize disclosure of separately maintained psychotherapy notes. Washington law specifically provides that psychotherapy notes may not be released without the patient's authorization.

MY USES AND DISCLOSURES

How do I typically use or share your health information?

I typically use or share your health information in the following ways.

Treat you

I can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run my practice

I can use and share your health information to run my practice, improve your care, and contact you when necessary.

Example: I use health information about you to manage your treatment and services.

Bill for your services

I can use and share your health information to bill and get payment from health plans or other entities.

Example: I give information about you to your health insurance plan so it will pay for your services.

HOW ELSE CAN I USE OR SHARE YOUR HEALTH INFORMATION?

I am allowed or required to share your information in other ways—usually in ways that contribute to the public good, such as public health and research. I have to meet many conditions in the law before I can share your information for these purposes.

Help with public health and safety issues

I can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone's health or safety

Do research

I can use or share your information for health research.

Comply with the law

I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that I'm complying with federal privacy law.

Reproductive health care

Federal law provides additional protections for protected health information related to reproductive health care. I will not use or disclose such information for the purpose of investigating or imposing liability on any person for seeking, obtaining, providing, or facilitating lawful reproductive health care.

Respond to organ and tissue donation requests

I can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

I can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers' compensation, law enforcement, and other government requests

I can use or share health information about you:

• For workers' compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

I can share health information about you in response to a court or administrative order. Under Washington law (RCW 70.02), if I receive a subpoena, mental health records will only be released with your written authorization, a qualifying court order, or after specific legal notice requirements under state law have been met.

MY RESPONSIBILITIES

• I am required by law to maintain the privacy and security of your protected health information.

• I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• I must follow the duties and privacy practices described in this notice and give you a copy of it.

• I will not use or share your information other than as described in this notice unless you tell me I can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

CHANGES TO THE TERMS OF THIS NOTICE

I can change the terms of this notice, and the changes will apply to all information I have about you. The new notice will be available upon request, on my website, and through your client portal.