Privacy Policy/HIPAA

Notice of Privacy Policies to Protect Your Personal Health Information

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

My practice is committed to protecting your privacy and confidentiality.

I.  Uses and Disclosures for Treatment, Payment, and Health Care Operations

The practice may use or disclose your protected health information (PHI), for treatment, payment and health care operations purposes with your consent.  To help clarify these terms, here are some definitions:

  • “PHI” refers to information in your mental health record that could identify you, ranging from your name or social security number to material contained in past or present treatment records that you may share with us.
  • “Treatment, Payment and Health Care Operations”:

Treatment is when my practice provides, coordinates or manages your health care and other services related to your health care.  An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.

Payment is when my practice receives payment from you. 

Health Care Operations are activities that relate to the performance and operation at my practice.  Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

  • “Use” applies only to activities within our office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  • “Disclosure” applies to activities outside of the practice, such as releasing, transferring, or providing access to information about you to other parties.
  • “Consent” refers to permission that you give, such as agreeing to allow the practice to notify your insurance company that you are in treatment so that you can receive reimbursement for services rendered.

II. Uses and Disclosures Requiring Authorization

The practice may use or disclose PHI for purposes outside of treatment and health care operations only by obtaining appropriate authorization for you.   An “authorization” is written permission from you that allow only specific disclosures.  In instances when Your therapist is asked to provide information about for purposes outside of treatment, payment, and health care operations, he must obtain authorization from you before releasing this information.  You may revoke all such authorizations at any time, provided each revocation is in writing.  You may not revoke an authorization to the extent that I have already acted on that authorization; or (2) if the authorization was obtained as s condition of obtaining insurance coverage, and the law provided the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent Nor Authorization

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

  • Child Abuse:  If I have reasonable cause to believe the at child has been subject to abuse, I must report this immediately to the New Jersey Division of Youth and Family Services.
  • Adult/Elder Abuse:  If I reasonably believe that a vulnerable adult or elderly person is the subject of abuse, neglect, or exploitation. I may report the information to the county adult protective services.
  • Health Oversight:  If the New Jersey State Board of Psychological Examiners issues a subpoena, I may be compelled to testify before the Board and produce relevant records and papers.
  • Judicial or Administrative Proceedings:  If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is privileged under state law, and I must not release this information without written authorization from you or your legally appointed representative, or court order.  This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. I must inform you in advance if this is the case.
  • Serious Threat to Health or Safety:  If you communicate to me an imminent threat to do serious physical violence against a readily identifiable victim or yourself or the public and I believe you intend to carry out that threat, I must take steps to warn and protect.  The steps I take to warn and protect may include arranging for you to be admitted to a psychiatric unit or hospital or other health care facility, advising the police of your threat and identity of the intended victim, warning the intended victim or his or her parents if the intended victim is under 18, and warning your parents if you are under 18.
  • Worker’s Compensation:  If you file a worker’s compensation claim, I may be required to release relevant information from your mental health records to a participant in the worker’s compensation case, a reinsurer, the health care provider, medical and non-medical experts in connection with the case, the Division of the Worker’s Compensation, or the Compensation Rating and Inspection Bureau.

IV. Patient’s Rights and Psychologist’s Duties


  • Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, I am not required to agree to a restriction you request.
  • Right to Receive Confidential Communications by Alternative Means and at Alternative Location: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations (e.g., You may not want a family member to know that you are seeing a therapist. Upon your request, I can send receipts to another address).
  • Right to Inspect and Copy: You have the right to inspect and copy (or both) of PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.  Your 
    • Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record.  Please be aware that I can deny your request; however, he will discuss with you the details of the amendment process at your request.
    • Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice).  At your request, I will discuss with you details of the accounting process.
    • Right to a Paper Copy: You have the right to obtain a paper copy of this notice upon request.


    • I am required by law to maintain the privacy of PHI and to provide you with a notice of his legal duties and privacy practices with respect to PHI.
    • The practice reserves the right to change the privacy policies and practices described in this notice.  Unless the practice notifies you of such changes, however, I am required to abide by the terms currently in effect.
    • If the practice revises this policy, I will provide you with a revised notice, either in person or by mail.

    V. Questions and Complaints

    If you have any questions about this notice, disagree with a decision I make about access to your records, or have other concerns about privacy rights, please discuss these issues with me.  If you believe that your privacy rights have been violated and wish to file a complaint, you may send or drop off your written complaint to the practice.  You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  I can provide you with appropriate address upon request.  You have specific rights under the Privacy Rule.  The practice will not retaliate against you for exercising your right to file a complaint.

    VI. Effective Date and Changes to Privacy Policy

    This notice will go into effect on January 1, 2007.  The practice reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain.  I will provide you with a revised notice either in person or by mail if there are any changes or updates to this policy.  I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed.  At your request, I will discuss with you details of the request and denial process.

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