Notice of Privacy Practice

As required by the privacy regulation created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), this notice describes how health information about you and your child (as a client of my mental health counseling or art therapy practice) may be used and disclosed and how you can get access to you/your child’s individually identified health information.

I am committed to maintain the privacy of your/your child’s Protected Health Information (PHI). In conducting my business, I will create records regarding you/your child and the treatment and services administered.

I may use and disclose your PHI in the following ways.

  1. Treatment – With your written consent, I may disclose and exchange your/your child’s PHI with other service providers and family members in order to support your/your child’s treatment. See the Consent For Disclosure and/or Exchange of PHI form.
  2. Payment – I may use and disclose your PHI in order to bill and collect payment from third parties (insurers) with your consent. See the Treatment Agreement Form for more details.
  3. Business Operations – I may use and disclose your/your child’s PHI to contact you for business purposes, for example, to remind you of an appointment. I may call your home or other alternate location and leave a message regarding appointments on voice mail. I may also mail correspondence to your home such as appointment reminder cards and payment statements.

Use and disclosure of your/your child’s PHI in Certain Special Circumstances are:

  • In the event of medical emergency, emergency personnel or services may be given any necessary information.
  • In the event of a threat to oneself or someone else, if that threat is perceived to be serious, the proper individuals must be contacted. This may include the individual against whom the threat is made.
  • In the event of suspected child or elder abuse, the proper authorities must be contacted. The actions do not have to be witnessed to be reported.
  • In certain select circumstances, judges can court order records of treatment
  • Records must be released when subpoenaed by an attorney in Washington State unless you file a Protection Order within 14 days
  • In the event of a patient’s death, the information may be released if the patient’s personal representative or the beneficiary of an insurance policy on the patient’s life signs authorizing disclosure
  • If you bring a complaint against your therapist with the State of Washington Department of Health

Your Rights regarding your PHI:

  1. Confidential Communication; You have the right to request that our practice communicate with you/your child about your/your child’s health and related issues in a particular manner or at a certain location.
  2. Requesting Restrictions; You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations.
  3. Inspection and copies: You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you. You must submit your request in writing.
  4. Amendment: to request an amendment, your request must be made in writing.
  5. Right to file a complaint Complaints may be directed to Department of Health, HSQA Complaint, PO Box 47857, Olympia, WA 98504-7857, (360) 236-4700
  6. Right to provide an authorization for other uses and disclosure.

If you have any questions regarding this notice or my health information privacy policies, please contact Mineko Takada-Dill, (206) 276-4915.