** THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Introduction to Clients
This notice will tell you about how I handle information
about you and your child. It tells how I use this information
in my office, how I share it with other professionals and
organizations, and how you can see it. I am required to tell
you about this because of a federal law, the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
In most situations I can only
release information about your treatment to others if you
sign a written authorization form that meets certain legal
requirements imposed by state law or HIPAA. Clients who are
13 or older must sign the written authorization form.
II. Your Medical Information
Each time you or your child visit me, information is collected
about your or your child’s physical or mental health.
It may be information about you or your child’s past,
present or future health or condition, the treatment or services
received, or about payment for health care. This information
is called PHI, which stands for Protected Health Information.
The information I obtain from you or your child goes into
your or your child’s medical record at my office.My records may be computerized or written and stored in paper files. Files are likely to include the following:
• Your or your child’s personal history
• Reasons you or your child came for treatment: problems,
symptoms, needs, goals
• Diagnoses: medical terms for your or your child’s
problems, symptoms, disabilities
• Treatment Plan: services that I think will help you
or your child
• Progress Notes
• Records from others who treated or evaluated you or
• Psychological test scores, school records, and the
• Information about medications you or your child are
• Legal matters
• Billing and insurance information
This information is used for many purposes. For example I
may use it to:
• Plan your or your child’s care
• Decide how well my treatment is working for you or your child
• Talk with other health care professionals who are
also treating you or your child, such as your family doctor
or a professional who referred you to me
• Show that you actually received the services from
me that I billed to you or your health insurance company
Because the records are of a professional and technical nature,
they can be misinterpreted or prove to be upsetting to an
untrained reader. For this reason I recommend that you initially
review them in my presence or have them forwarded to another
mental health professional so you can discuss the contents.
In most situations I am allowed to charge a reasonable fee
for copying those records. If I refuse your request for access
to your records, you have a right of review, which I will
discuss with you upon request. In the event that I become
incapacitated, psychologist Fredric Provenzano, Ph.D. will
become custodian of my records and will assume their management.
His office phone number is (206) 361-2343.
If you find anything in the records that you think is incorrect
or something important is missing, you may ask me to amend
(add information to) your record. In some rare situations,
I do not have to agree to that.
III. How Protected Health Information
Can Be Used and Shared
When your or your child’s information is read by me
or others in my office, it is called “use.” If
the information is shared with or sent to others outside this
office, it is called “disclosure.” Except in some
special circumstances, when I use your or your child’s
PHI or disclose it to others, I share only the minimum necessary
PHI needed for the purpose. The law gives you rights to know
about your PHI, how it is used, and to have a say in how it
IV. Uses and Disclosures of PHI in
Health Care with Your Consent
I need information about you or your child in order to provide
satisfactory treatment and evaluative services for you. It is necessary that I collect that information, use it,
and share it as necessary. Therefore, you must sign the Client
Services Agreement before I begin to provide services for
you or your child. If you do not give your consent, I cannot
treat or evaluate you or your child. Generally, I may use
or disclose your or your child’s PHI for three purposes:
treatment, obtaining payment and communicating with third
party payors about payment, and what are termed health care
operations. If I have assistants helping with my practice,
they will follow the same legal guidelines.
Treatment. I might use your medical information
to provide you or your child with psychological services or
treatment. These might include individual, family, or group
therapy, psychological or educational testing, treatment planning,
or measuring the effects of my services.
I might share or disclose your or your child’s PHI
to others who provide treatment to you or your child, including
your personal physician. I may occasionally find it helpful to
consult other health and mental health professionals about
a case. If I consult with a professional who is not involved
in your treatment, I make every effort to avoid revealing
your identity. These professionals are legally bound to keep
the information confidential.
I may refer you or your child to other professionals or
consultants for services that I cannot or choose not to offer, such as special
testing or treatments. When I do this, I need to tell those
people things about your and your child’s conditions.
I may leave a message for you regarding an appointment.
Please fill out the "Authorization to Leave Personal Health Information by Alternate Means" so that I may comply with your wishes. If you want me to call you only at work or at home, I can
usually arrange for that. I often leave messages on home answering
machines. If this creates a problem, please let me know. I
use cell and cordless phones, so privacy cannot be absolutely
guaranteed with these devices.
Payment. I may use your information to bill you,
your insurance, or others in order to be paid for the evaluation
and treatment I provide to you or your child. I may contact
your insurance company to determine what your insurance covers.
I may have to tell them your or your child’s diagnoses,
dates of service, and what treatments you have received.
Health Care Operations. There are some other ways
I may use or disclose your PHI, which are called health care
operations. For example, I may be required to supply information
to some government health agencies so they can study disorders
and treatment and make plans for services that are needed.
If I do, your or your child’s name and identity will
be removed from what I send.
Business associates may assist me with tasks like billing,
filing, and taking messages. These assistants need to receive
some of your or your child’s PHI to perform these services
properly. To protect your privacy, they will safeguard your
and your child’s information.
V. Uses and Disclosures Requiring
If I want to use your or your child’s PHI for any
purpose besides those described above, I need your written
permission on an authorization form. If you do authorize me
to use or disclose your or your child’s PHI, you can
revoke that permission in writing at any time but this will not affect any use or disclosure made by me before the disclosure.
If you want me to share information about you or your child
with your family or close others, I will ask you what information
you want me to share and with whom.
VI. Uses and Disclosures of PHI from
Mental Health Records Not Requiring Consent or Authorization
If you are involved in a court proceeding and a request is
made for information concerning the professional services
I provided you, such information may be protected by the law. I cannot provide any information without your written authorization or a court order requiring the
disclosure. If you are involved in or contemplating litigation,
you should consult with your attorney about likely court disclosures.
If a governmental agency requests your or your child’s
PHI for health oversight activities, I may be required to
provide it to them. If a patient files a complaint or lawsuit
against me, I may disclose relevant information regarding
that patient in order to defend myself. If a patient files
a worker’s compensation claim and the services I am
providing are relevant to the injury for which the claim was
made, I must, upon appropriate request, provide a copy of
the patient’s record to the patient’s employer
and the Department of Labor and Industries.
In some situations I am legally obligated to take actions
that I believe are necessary to attempt to protect others
from harm and I may have to reveal some information about
a patient’s treatment. These situations are unusual.
If I have reasonable cause to believe that a child has suffered
abuse or neglect, the law requires me to file a report with
the appropriate government agency, usually the Department
of Social and Health Services. Once such a report is filed,
I may be required to provide additional information. If I
have reasonable cause to believe that abandonment, abuse,
financial exploitation, or neglect of a vulnerable adult has
occurred, the law requires me to file a report with the appropriate
government agency, usually the Department of Social and Health
Services. Once such a report is filed, I may be required to
provide additional information. If I reasonably believe that
there is imminent danger to the health or safety of the patient
or any other individual, I may be required to take protective
actions. These actions may include notifying the potential
victim, contacting the police, seeking hospitalization for
the patient, or contacting family members or others who can
help provide protection.
If such a situation arises, I will make every effort to discuss
it fully with you before taking any action. I will limit my
disclosure to what is necessary.
While this summary of exceptions to confidentiality should
help inform you about potential problems, it is important
that we discuss any questions or concerns that you now have
or develop in the future. The law governing confidentiality
can be complex. In situations where specific advice is required, you may need
formal legal advice.
VII. Patient Rights
In summary, HIPAA and Washington State law provide you with
certain rights regarding your clinical record and disclosure
of protected health information about you. These rights include:
• requesting that I amend your record
• requesting restrictions on what information from your
clinical record is disclosed to others
• requesting an accounting of most disclosures of protected
health information that you have neither consented to nor
• determining the location to which protected information
disclosures are sent
• having any complaints you make about my policies and
procedures recorded in your records
• receipt of a copy of this Notice of Privacy Practices
VIII. Exclusions from Disclosure Involving Minor Children
If I am to provide therapy or testing services for your minor child, you generally have the right to inspect and copy (within certain limitations and after payment of a reasonable fee) my records used by me to make decisions about your minor child. Two primary exceptions apply to this right to inspect and copy:
• Notes containing statements made by your minor child in therapy sessions are protected by the child's right to confidentiality. They will not be disclosed or released to you unless required by law or unless I decide that disclosure is in the best interests of the child.
Test data (other than test results) and materials are protected by the owners and publishers of standardized psychoeducational, behavioral, and academic tests. Disclosure by me of the raw data and materials to anyone other than a licensed professional qualified to interpret the data is prohibited.
IX. An Accounting of Disclosures
When I disclose your or your child’s PHI, I will keep
a record of what was sent, when I sent it and to whom it was
sent. You may ask for it at any time.
If you need more information or have questions about these
privacy practices, please ask me. If you have a problem with
how your or your child’s PHI has been handled, or if
you believe your or your child’s privacy rights have
been violated, please let me know. You have the right to file
a complaint with me and with the Secretary of the Federal
Department of Health and Human Services. I will not in any
way limit your or your child’s care or take any actions
against you if you complain. I am the designated privacy officer
for my practice and can be reached by phone at (206) 465-8068.