Notice of Privacy Practices

EFFECTIVE DATE: APRIL 14, 2003

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 health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information ("PHI"). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable Federal and State law. It also describes your rights regarding how you may gain access to and control your PHI

I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request or providing one to you at your next appointment.

I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
A. Treatment: The information you provide to me will be recorded in your record and used to decide what care is right for you. I will request your permission to give to or receive from other health care providers (for example your physician, or previous counselors) information that you and I agree is important to be shared, in order for you to receive the best care. I will receive consultation from time to time from a consultant or colleagues. If I discuss your treatment, I will not use any identifying information in order to protect your confidentiality.

B. Payment: I may use or disclose PHI so that services you receive are appropriately billed to and payment is received from your health plan. I will ask your permission to reveal necessary information for billing purposes.

C. Psychotherapy Notes: Notes I record documenting the contents of a counseling session with you ("Psychotherapy Notes") will be used only by me, and will not otherwise be used or disclosed without your written authorization. However, as explained in my disclosure statement, in the following situations I could not maintain the confidentiality of my notes or your PHI;
• In cases of suspected abuse or neglect
• If I believed your or another's life was endangered
• To the extent disclosure is required by law
• If I was served with a court order requiring me to provide PHI

D. Marketing Communications: I will not use your health information for marketing communications without your written authorization.

E. Other uses and Disclosures: Uses and disclosure other than those described above will only be made with your written authorization

II. YOUR INDIVIDUAL RIGHTS
You have the following rights with respect to the information in your medical record, including the right to:

A. Inspect and Copy. You may request access to your medical record and billing records maintained by me in order to inspect and request copies of the records. All requests for access must be made in writing. I may deny access to your records only in those situations where there is compelling evidence that access would cause serious harm to you. I may charge a reasonable cost-based fee for copying and sending you any records requested. If you are a parent or legal guardian of a minor, please note that certain portions of the minor's medical record will not be accessible to you.

B. Request Confidential Communications. You have the right to request that I communicate with you about anything related to your treatment in a certain way or at a certain location.

C. Request Restrictions on PHI used for disclosure for treatment, payment or health care operation. You must request any such restriction in writing. I am not required to agree to your request.

D. Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made by me after April 14, 2003. This right applies to disclosures for purposes other than treatment, payment or health care operations, and excludes disclosures made to you or disclosures otherwise authorized by you.

E. Request Amendment. If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information, although I am not required to agree to the amendment.

F. Obtain Notice. You may receive a paper copy of this notice by requesting it from me at any time.

Questions and Complaints. If you wish further information about your privacy rights, or are concerned that I have violated your privacy rights, please let me know. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W. Washington D.C. 20201, or by calling (202)619-0257 I will not retaliate against you if you file a complaint.

Understanding and Agreement
My signature below certifies that I have received and read Susan Goedde's Disclosure Statement , the State of Washington's brochure "Counseling or Hypnotherapy Clients" and her Notice of Privacy Practices. I have had an opportunity to ask any questions I may have about these statements, the information in the brochure, and working with Susan, and I understand and agree to the policies stated in these documents.

(Client signature) _______________________________Date:________

My signature below means that I have provided you with the Disclosure Statement, with a copy of the Washington State brochure "Counseling or Hypnotherapy Clients", and with my Notice of Privacy Practices.

(Therapist signature)____________________________Date:_________

Copyright © 2004
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