HIPPA Notice



HIPAA Hooray! Starting April, 2003, a new law named HIPAA established greater safeguards for patient privacy, and the law requires that I provide to all clients a description of how the rules of privacy are applied in my practice. This document serves as that notice.

The law protects the privacy of all communications between a patient and a psychologist or counselor. 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 HIPAA. We will go over that form together if there ever is specific need for it.

However, there are certain other situations that require only that you provide written consent one time, for example at the start of therapy. I will be asking for you to give consent for me to disclose certain information about you, which is necessary for me to work effectively and to get paid. The following six points explain the types of disclosure that I generally need for every client.

  • Consultation: I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record.
  • Routine administration: I practice with other mental health professionals and I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals and staff members are bound by the rules of confidentiality. When we contact you for administrative purposes, such as billing or scheduling appointments, we will use the telephone numbers and mailing address you provide, and we will use discretion when leaving any messages for you. You may direct us to even further restrict disclosure, for example not leaving messages on your machine.
  • Insurance payment: If you want your insurance to pay or reimburse for my services, I will provide it with information relevant to the services that I provide to you. Generally, I am required to provide a clinical diagnosis, and sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though the insurance companies are required by HIPAA to treat patient information in a confidential manner, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit, if you request it.
  • Collection: If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.
  • Children’s privacy: Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from parents that they consent to give up their access to their child’s records. I will provide parents only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions, unless I find an imminent threat of harm to self or others.
  • Safety: If any patient threatens to harm himself/herself or others, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection.

There are also some situations where I am permitted or required by law to disclose information without either your consent or Authorization: These situations are unusual in my practice. The following six points explain these unusual circumstances.

  • Child abuse: If I know or suspect that a child under the age of 18 has been abused or neglected, the law requires that I file a report with the appropriate governmental agency, usually the Alabama Department of Human Resources. Once such a report is filed, I may be required to provide additional information.
  • Elderly abuse: If I know that an elderly or disabled adult has been abused, neglected, exploited, sexually or emotionally abused, the law requires that I file a report with the appropriate governmental agency, usually the Alabama Department of Human Resources. Once such a report is filed, I may be required to provide additional information.
  • Safety: If I believe that disclosing information about you is necessary to prevent or lessen a serious and imminent threat to the health and safety of an identifiable person(s), I may disclose that information, but only to those reasonably able to prevent or lessen the threat.
  • Legal proceedings: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. However, if a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
  • Health oversight activities: If a government agency is requesting the information for health oversight activities, I am required to provide it for them.
  • Worker’s Compensation: If a patient files a worker’s compensation claim, I may disclose information relevant to that claim to the patient’s employer or the insurer.

If one of these situations arises, I will make every effort to fully discuss it with you before taking any action and I will try to limit my disclosure to what is necessary.


You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. If you provide me with an appropriate written request, you have the right to examine and/or receive a copy of your records, except in unusual circumstances that involve danger to you or others. In those situations, you have a right to have your record sent to another mental health provider. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. 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 addition, I may also keep a set of Psychotherapy Notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal.  You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that such disclosure would be reasonably likely to endanger your health.



HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. 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 authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Notice form and Agreement. I am happy to discuss any of these rights with you, and our office manager will provide you with the forms necessary for you to request any of these activities.



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 discuss it with me. If you prefer you may contact our office manager, Michelle Gurley.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C. 20201.

You have specific rights under the Privacy Rule.  I will not retaliate against you for exercising your right to file a complaint.


This notice will go into effect on April 15, 2003.

I reserve the right to change the terms of this notice and to make the new notice provisions effective for all Protected Health Information that I maintain.  I will provide you with a revised notice by mail.