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Confidentiality Notice

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.

I. Uses and Disclosures

According to Federal Law, I may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your consent. PHI refers to information in your health record that may be used to identify you. In all cases where use or disclosure is necessary, In such situations, I will disclose only the minimum amount of information necessary for the stated purpose.

Use refers to activities within my practice; Disclosure refers to activities outside of my practice, that is transferring or releasing information to another party.

Treatment: when a health care provider provides, coordinates, or manages your health care and other services related to your health care. An example of using or disclosing PHI for treatment may include if I were to consult with another health care provider or provide psychotherapy with another family member present at your request.

Payment: when a health care provider obtains reimbursement for your healthcare. Examples of use or disclosure of PHI for payment are when I submit a bill to your health insurer or other requested 3rd party payer to receive payment for your care; or if I use a business associate to submit such claims. If you are using insurance, you have an agreement with them that your record is available for utilization or medical review if needed to approve payment. I may use a business associate for assistance in billing.

Healthcare operations: activities which relate to the performance and operation of my practice. Examples of use or disclosure for healthcare operations may include quality assessment, credentialing, medical or utilization review, audits, appointments etc. In performing such functions, we may rely on certain business associates to assist us.

II. Uses and Disclosures With Authorization

I may use or disclose your PHI for purposes outside of treatment, payment, or healthcare operations if your authorization is obtained. “Authorization” means that you have provided written permission beyond any general consent form. You may revoke an authorization for future release at any time, provided such revocation is in writing. You may not revoke an authorization related to situations where I may have already relied on such authorization for past use or disclosure. If the authorization was obtained as a condition of obtaining insurance coverage, the law provides the insurer the right to contest the revocation under the policy.

I may use your PHI in order to provide communication about appointments or in relations to charges for missed appointments or late cancellations.

I may use your PHI in order to provide you with referrals to other health related services which may be of interest to you. I will not disclose your PHI for referrals without your consent.

III. Uses and Disclosures without Consent or Authorization

I may use or disclose your PHI without your consent or authorization under the following circumstances:

Child Abuse: If I have reasonable cause to believe a child (person under the age of 18) has been abuse or severely neglected, I must report this belief to an appropriate authority.

1 HIPAA notice; August 2010
Elder or Disabled Adult Abuse: If I have reasonable cause to believe that a disabled adult or elderly person has been abused, severely neglected, or exploited, I must report that belief to an appropriate authority.

Health Oversight: If I am the subject of an inquiry by the Georgia Board of Psychological Examiners, I may be required to disclose PHI regarding you in proceedings before the Board.

Judicial and Administrative Proceedings: If you are involved in a court proceeding, and a request is made about the professional services I have provided to you, including disclosure of records, such information is considered privileged. I will not release such information without appropriate written authorization from you unless I am in receipt of a legitimate court order (not a subpoena).

Serious Threat to Health or Safety: If I determine or believe that you present an imminent and serious danger to yourself or someone else, I may disclose such information as I believe necessary in order to provide protection against such danger for you or any other intended victim.

Incapacitation Notification: If you become physically injured and/or incapacitated while in my presence or offices, I may notify a family member, your personal representative, or other listed emergency contact person responsible for your care, of your location, general condition, or death. If you are able, we will provide you an opportunity to object before disclosing any such information. In the event of my death or I become incapacitated and unable to provide care, a designated psychotherapist will use your file to contact you and help determine appropriate follow-up care and/or resources.

Other areas required by Law: I may need to disclose PHI as required by law and to the extent necessary to comply with Worker’s Compensation Claims, National Security and Intelligence Issues, FTC identity theft investigations, etc.

IV. Patient’s Rights and Psychologist Duties Right to Request Restrictions:

You have the right to request restrictions on certain uses and disclosures of protected health information. However, your health care provider is not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing your health care provider. On your request, your health care provider will send your bills to another address.)

Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in your health care provider’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your health care provider may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, your health care provider will discuss with you the details of the request and denial process. You do not have a right to inspect or copy psychotherapy notes, which are not considered part of the Clinical File. However, you may still request to inspect and copy psychotherapy notes or have the disclosed to another licensed health care provider, and in many instances I will comply with the request.

Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your health care provider may deny your request, but will document your request. On your request, your health care provider will discuss with you the details of the amendment process.

Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI. On your request, your health care provider will discuss with you the details of the accounting process.

Right to a Paper Copy: You have the right to obtain a paper copy of the notice from this office upon request, even if you have agreed to receive the notice electronically.

2 HIPAA notice; August 2010

V. Questions and Complaints

If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me at 2200 Century Blvd, Suite 200, Atlanta GA 30345, or at any phone number listed on my website,

If you believe that your privacy rights have been violated and wish to file a complaint, you may send your written complaint to me at 2200 Century Parkway, Suite 200, Atlanta GA 30345
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. You have specific rights under the Privacy Rule. This office will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice is effective September 1, 2010. I reserve the right to change the terms of this notice, make restrictions or limitations, and to make the new notice provisions effective for all PHI that I maintain. A written copy will be provided upon written request. The most recent electronic copy is available on my website, at

I have received and read this notification:

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