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Effective Date: September 23, 2013






Health information about your health is personal; I am committed to protecting your privacy and health information.  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 me.  


This notice will tell you about the ways in which I may use and disclose health information about you.  I also describe your rights and certain obligations I have regarding the use and disclosure of health information.  


I am required by law to:

  • Make sure that health information that identifies you is kept private

  • Give you this notice of my legal duties and privacy policies with respect to health information about you

  • Follow the terms of the notice that I have currently in effect

  • Comply with any state law that is more stringent or provides you greater rights that this Notice



You have the following rights regarding information I maintain about you:


  • Right to Request Restrictions - You have the right to request a restriction or limitation on the health information I use or disclose about you for treatment, payment or health care operations.  I am not required to agree to your request.  If I do agree, I will comply with your request unless the information is needed to provide you emergency treatment.  


You also have the right to request a limit in the health information I disclose about you to someone who is involved in your care or the payment for your care, like a family member.  For example, you could ask that I not use or disclose information about a psychotherapy session you received. I will comply with your request unless the information is needed to provide you emergency treatment.  


To request restrictions, you must make your request in writing to me.  In your request, you must tell me (1) what information you want to limit, (2) whether you want to limit my use, disclosure or both, and (3) to whom you want the limits to apply, for example, disclosure to your spouse.  


While I maintain records of your care, I do not maintain or keep psychotherapy process notes.  


Lastly, if you pay for psychotherapy services in full and out of pocket without insurance reimbursement, you can request that I restrict the disclosure of protected health information to your insurer.  


  • Right to Request Confidential Communications – You have the right to request that I communicate with you about health matters in a certain way or at a certain location.  For example, you can ask that I only contact you at work or by mail.  To request confidential communications, you must make your request in writing to me.  I will not ask you the reason for you request.  I will accommodate all reasonable requests.  Your request must specify how or where you wish to be contacted. 


  • Right to Review and Copy – You have the right to review and copy health information that may be used to make decisions about your care.  This may include both health and billing records.


To review and copy health information that may be used to make decisions about you, you must submit your request in writing to me.  If you request a copy of the information, I may charge a fee for the costs of copying, mailing, or other supplies associated with you request.


I may deny or limit access to your request to inspect and copy in certain very limited circumstances.  If you are denied or limited access to health information, you may request that the decision be reviewed.  Another health care professional chosen by me will review your request and the denial.  I will comply with the outcome of the review. 


  • Right to Amend – If you feel that health information I have about you is incorrect or incomplete, you may ask me to amend the information.  You have the right to request an amendment for as long as the information is kept by or for me.  


To request an amendment, your request must be made in writing and submitted to me.  In addition, you must provide a reason that supports your request.  


I may deny your request for an amendment if it is not in writing or does not include a reason to support that request.  In addition, I may deny your request if you ask me to amend information that:

  • Was not created by me, unless the person or entity that created the information is no longer available to make the amendment

  • Is not part of the designate record set kept my me

  • Is not part of the information which you would be permitted to inspect and copy, or, 

  • Was determined accurate or complete by me. 


  • Right to an Accounting of Disclosures - You have the right to request an “Accounting of Disclosures.”  This is a list of disclosures I made of health information about which were required by law and/or were not authorized by you.  


To request this list or accounting of disclosures, you must submit your request in writing to me.  Your request must state a time period, which may not be longer than six years and may not include dates before 9/23/2013.  Your request should indicate in what form you want the list (for example, on paper, electronically).  The first list you request within a 12-month period will be free.  For additional lists, I may charge you for the costs of providing the list.  I will notify you for the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. 


  • Right to a Paper Copy of this Notice – You have the right to a paper copy of this notice.  You may ask me to give you a copy of the current notice at any time. To obtain a paper copy of this notice, please contact me.


  • Right to be made aware of data breaches – You have the right to be notified of a breech in protected health information when it is determined your information was compromised, or in cases where large amounts of information are breeched and your data is assumed to be among the data compromised.  You will be notified in writing unless you have specifically asked not to be contacted in writing.


  • Specific Requirements for electronic notice - A covered entity that maintains a web site that provides information about the covered entity’s customer services or benefits must prominently post its notice on the web site and make the notice available electronically through the web site.



The following categories describe different ways that I use and disclose health information.  For each category of uses of disclosures I will explain what I mean and try to give some examples.  Not every use or disclosure in a category will be listed.


  • For Treatment – I may use health information about you to provide you with treatment or services.  I may speak to other people involved in your health care.  For example, I may need to speak with your primary care physician or a specialist to make a referral or to coordinate care.


  • For Payment – I may use and disclose health information about you so that the treatment and services you receive from me may be approved by, billed to, and payment collected from a third party such as an insurance company.   For example, I may need to give your health plan information about therapy you received from me so your health plan will pay me or reimburse you for a therapy session.  I may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the service/treatment.  


  • Appointment Reminders – I may use and disclose information to contact you as a reminder that you have an appointment.  


  • Alternative Treatment and Benefits and Services – I may use and disclose information about you in order to obtain and recommend to you other treatment options and available services as well as other health-related benefits or services. 


  • As Required By Law – I will disclose medical information about you when required to do so by federal, state or local law.  In Vermont, this would include: suspicions of child abuse, suspicions of abuse, neglect or exploitation of vulnerable adults, or where a child under the age of 16 is victim of a crime, and firearm-related injuries.  


  • To avert a serious threat to health or safety – I may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.  Any disclosure, however, would only be to someone able to help prevent the threat. 


  • Military and Veterans – If you are a member of the armed forces, I may release health information about you as required by military command authorities.


  • Workers’ Compensation – I may release health information about you as authorized for workers’ compensation or similar programs as authorized by Vermont law.  These programs provide benefits for work-related injuries or illnesses.


  • Legal Proceedings and Disputes – If you are involved in a lawsuit or a dispute, I may disclose health information about you in response to a court order.  



Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission.  If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, I will no longer use or disclose health information about you for the reasons covered by your written authorization.  You understand that I am unable to take back any disclosures I have already made with your permission, and that I am required to retain my records of the services that I provided to you.



I reserve the right to change this notice.  I reserve the right to make the revised or changed notice effective for health information I already have about you as well as any information I receive in the future.  I will post a copy of the current notice in my waiting room and on my website.  The notice will contain on each page, in the top right-hand corner, the effective date and the most current date of revision.  In addition, should I make a material change to this notice, I will, prior to the change taking effect, publish an announcement of the change on my website and in my waiting room.  A new notice will be distributed to you.



If you believe your privacy rights have been violated, you may file a complaint with me or with the Secretary of the Department of Health and Humans Services.   All complaints must be submitted in writing.  You will not be penalized for filing a complaint.

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