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Notice of Privacy Practices

Effective: October, 2023

This document contains important information regarding how your medical information will be used, retained, and disclosed as a participant in therapy.


  1. Overview for clients

  2. What is “medical information”?

  3. Privacy laws

  4. Written permission for disclosure

  5. Disclosures not requiring written consent

  6. Client privacy rights

  7. Record keeping

  8. Privacy breaches

  9. Questions & concerns

Overview for Clients

It is important for clients to understand how your medical information is protected, shared, and accessed so you can make informed decisions throughout your counseling services. You will have access to this form in your patient portal so that you may review it at any point, and you are welcome to discuss details with me at any point in therapy.

What is "Medical Information"?

Private medical information (PHI) refers to data and details I collect from you that is contained within your medical records. This includes, but is not limited to:

  • Identifying information like your name, address, birth date, or contact information;

  • Progress notes, which contain brief summaries of our sessions;

  • Treatment plans, which describe therapy goals and services;

  • Diagnoses;

  • Medications;

  • Assessments, screenings, and evaluations conducted;

  • Dates of service;

  • Billing and insurance information;

  • Records received from other providers with your authorization;

  • Legal correspondence


I am required by law to maintain a record of your medical information. The following describe how your PHI may be used:


  • To plan, deliver, and evaluate effective treatment tailored to your specific needs;

  • To coordinate with other care providers;

  • To document that you received counseling services from me, in case this record is needed for insurance or legal matters.

  • To improve health care operations and services through professional consultation, business management, and licensing as permitted by law.

Privacy Laws

I adhere to the following laws intended to protect your medical information:

  • The Health Insurance Portability and Accountability Act of 1996 (HIPAA): This federal law requires that I keep your medical records private and provide this documentation detailing my legal duties and privacy practices. I will notify clients of any updates to my privacy practices, and store a copy in your patient portal for you to access.

  • 42 CFR Part 2: This federal act provides additional privacy protections for clients seeking treatment for substance use, to encourage participation in care. 

Written Permission for Disclosure

In many instances, I am required to obtain your written permission to share PHI with third-party. This written permission is documented in a form called an “ROI,” which stands for Release of Information. You may identify which aspects of treatment (i.e., treatment progress, evaluation, billing) you consent to disclosure. You may revoke a completed ROI at any point in treatment.


The following are examples of contacts which would require your written permission in the form of an ROI:


  • A parent or caregiver for clients age 13 and above;

  • Your probation officer and/or legal counsel regarding a legal matter;

  • Social services for which you are seeking benefits

Disclosures Not Requiring Written Consent

Please read the below information carefully, as it outlines disclosure of your medical information which does not require prior written consent. Know that as your collaborator, I will do my best to discuss any necessary disclosures with you prior to my outreach, though in some urgent situations, this may not always be possible.


The following describes reasons for which I must or may disclose details relating to your care or PHI:


  1. Per Washington State Law, I must report to the appropriate state agency reasonable cause to believe that a minor or vulnerable adult has suffered abuse or neglect. I must inform the appropriate enforcement agency (i.e., Child Protective Services) within 48 hours.

  2. If you express intent to harm yourself or another individual, I may reach out to your emergency contact, crisis services, the person you have stated intent to harm, or an appropriate state agency. I will always first collaborate with you to develop a safety plan before reaching out to third-party support when possible. The intent of such disclosure will be to prevent harm to yourself or others in the community.

  3. Per Washington State Law, I must make a report to the Washington Department of Health licensing board if I learn of another licensed medical professional who has exploited or engaged sexually with a client, or is practicing while impaired (cognitively, emotionally, behaviorally, or due to health or a substance) in a way that compromises a client’s safety.

  4. If a balance for services is not paid within 60 days and we have not agreed upon an alternative payment arrangement, I may pursue means of securing payment such as hiring a collections agency. In organizing collections, I will provide minimal detail such as your name, services received, and the amount owed.

  5. I may share PHI with other professionals providing you care, such as your psychiatrist or physician, for the purposes of improving your treatment. If you pursue a provided referral or receive care from professionals in the future, I may provide information that supports your care.

  6. If you choose to utilize insurance benefits. Insurance may require or request details from your medical record, such as diagnosis, date of services, and treatment you have received.  If your insurance provider audits my practice, the reviewers will have access to your file.

  7. I may disclose PHI in certain legal cases. If I must respond to a subpoena, warrant, or another administrative or court order, I may provide only the relevant and specific information solicited. Information may be privileged under Washington State Law. I will attempt to collaborate with you and your legal counsel before releasing information, unless you are being evaluated by court order. If you engage in a malpractice suit against me, the courts allow me to share details disclosed during counseling.

  8. If you are incapacitated or in the event of an emergency (for example, if you are unable to communicate and I believe that you would consent to medical attention).

Client Privacy Rights

  • You have the right to choose how I contact you.

  • You have the right to release your medical records to others, with written authorization. You may also provide a written revocation of released records; however, this cannot apply to records that you have already authorized for release.

  • You have the right to make a written request to inspect and/or copy your records. You agree to pay for mailing costs. I may deny this request in certain circumstances.

  • You have the right to make written requests to have your record amended. I will have 30 days to either accommodate or deny your request. If denied, you have a right to submit a disagreement statement, which will be filed with my response.

  • You have the right to make a written request of disclosures made of your health records with the following exceptions: disclosure for treatment, payment, or healthcare operations; disclosures pursuant to a signed release; disclosures made to the client; disclosures for national security or law enforcement purposes.

  • You have the right to make a written request that restricts the uses and disclosure of your healthcare information. I may deny this request, in which case you have the right to complain first to me and second to the US Department of Health and Human Services.

  • You have the right to be notified:

    • If I make any changes to privacy policies;

    • If your PHI has been breached or used in a way that violates HIPAA;

    • If your PHI is not encrypted to HIPAA standards.


Other rights may be entitled by state or federal law. If you have questions or concerns about your rights, please discuss with me and I will do my best to find answers for you

Record Keeping

In accordance with Washington laws and the standards of the counseling profession, I maintain treatment records in a secure and protected location for five years after the date of your final visit. All records and documentation will be securely maintained, and any electronic material will be stored in a HIPAA-compliant format and platform.


I record minimal detail about each session such as when you were seen, presenting issues, progress notes, and results from formal consultations. You may submit a written request that I do not keep records of details that emerge in session, though I am required by law to maintain basic information such as your name, fees, and dates. You have a right to receive a copy of your records, and I highly recommend we review any notes together whenever possible so you may ask questions about contents.


In the event of my death, incapacitation, or sudden departure from practice, your records will be transferred directly to my supervisor for the purposes of contacting you regarding my death/incapacitation/departure, billing issues, and arranging for records storage.

Privacy Breaches

If you have any additional questions regarding rights, policies, and laws relating to your private medical record, please reach out to me directly at If you believe that your privacy rights have been violated, you have the right to choose how you may address the issue:

  1. Submit your complaint to me directly. I take your concerns to heart, and appreciate any opportunity to collaboratively resolve issues.

  2. Submit a complaint to the Secretary of the U.S. Department of Health and Human Services. 

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