406 S First St., Suite 308
Mount Vernon, WA., 98273
Phone: (360) 424-0400
Fax: (360) 336-3270

Notice of HIPPA Privacy Practices

This notice describes how medical information about you may be used and disclosed according to the Health Information Privacy and Portability Law (HIPPA). All healthcare Providers are required by law to provide you with this information. We apologize ahead of time for the length and complexity of this notice. Please review it carefully and discuss any questions you may have with your therapist at your first session.

We respect your privacy, and we understand that your personal health information is very sensitive. Your therapist will not disclose your information to others unless you tell him or her to do so, or unless the law authorizes or requires this disclosure.

The law protects the privacy of health information, which your healthcare providers create and maintain concerning services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows your providers to use and disclose your protected health information for purposes of treatment and health care operations. State law requires your therapist to get your authorization to disclose this information for payment purposes.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations

For Treatment:

  • Information obtained will be recorded in your medical record and used to help decide what care may be right for you.

Your provider may also provide information to others who provide healthcare to you. This will help your treatment providers stay informed about your care.

For Payment:

  • Unless you instruct your therapist otherwise, he or she will generally request payment from your health insurance plan. Health plans need basic information from your provider about your medical care. Information usually provided to health plans includes your diagnoses, dates and services performed. If you have entered into a contract with a managed care group you may have also granted permission for them to access information about your symptoms, recommended care and treatment progress.

For Health Care Operations:

  • Your therapist may use your medical records to assess quality and improve services.
  • Your therapist may contact you to remind you about appointments and give you information about treatment alternatives or other health-related benefits and services.
  • Your therapist may use and disclose your information to conduct or arrange for services, including:
    • medical quality review by your health plan;
    • accounting, legal, risk management, and insurance services:
    • audit functions, including fraud and abuse detection and compliance programs.

Your Health Information Rights:

The health and billing records your therapist creates and stores are the property of this behavioral health/psychological practice. The protected health information in it, however, generally belongs to you. You have a right to:

  • Receive, read, and ask questions about this Notice;
  • Ask your therapist to restrict certain uses and disclosures. For legal purposes, you must deliver this request in writing to your therapist. Your therapist is not required by law to grant your request. Your therapist will either comply with your request or will give you a written explanation about why he/she is not doing so.
  • Request and receive from your therapist a paper copy of his/her most current Notice of Privacy Practices for Protected Health Information.
  • Request that you be allowed to see and get a copy of your protected health information. You must usually make this request in writing.
  • Have your therapist review a denial of access to your health information-except in certain circumstances as required by law.
  • Ask your therapist to change your health information. You must give your therapist this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your medical record, and included with any future release of your records.
  • If you request, your therapist will give you a list of disclosures of your health information. This list will not include disclosures to third-party payors.
  • Ask that your health information be given to you by another means or at another location. Please sign, date and give your request in writing to your therapist.
  • Cancel prior authorizations to use and disclose health information by giving your therapist a written revocation. Your revocation does not affect information that has already been released. It does not affect any action taken before your therapist has it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance payment.

For help with these rights during normal business hours, please contact your therapist by telephone at his/her office.

Provider Responsibilities:

Your therapist is required by law to:

  • Keep your protected health information private to the extent outlined in this notice.
  • Make this notice available to you and give you a copy if you request it.
  • Follow the terms of this notice.

Skagit Behavioral Health Therapists prefer to obtain your written or verbal permission before disclosing information to other parties, even when such disclosures are legally permitted without your consent. We have the right to change our practices regarding the protected health information we maintain.

If we make changes, we will update this notice. You may receive the most recent copy of this notice by calling and asking for it or checking our website.

To Ask for Help or Complain.

If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact your provider at his/her office telephone number.

If you believe your privacy rights have been violated, you may discuss your concerns with your therapist. You may also deliver a written complaint to Skagit Behavioral Health, 406 S. 1st, Mt. Vernon, WA 98273. You may also file a complaint with the U.S. Secretary of Health and Human Services.

Your therapist respects your right to file a complaint with him or her, or with the U.S. Secretary of Health and Human Services. If you complain, your therapist will not retaliate against you.

Other Disclosures and Uses of Protected Health Information

Notification of Family and Others

  • Unless you object, the law allows your therapist to release health information about you to a friend or family member who is involved in your medical care. Your therapist may also give information to someone who helps pay for your care. Your therapist may tell your family or friends your condition and that you are in a hospital. In addition, your therapist may disclose health information about you to assist in disaster relief efforts.

You have the right to object to such use or disclosure of your information. If you object, your therapist will not use or disclose it unless allowed or required to do so by law or in a potentially life-threatening situation(as per below).

Your therapist may use and disclose your protected health information without your authorization as follows:

  • To Comply with Workers' Compensation Laws - If you make a Workers' Comp. Claim.
  • For Public Health and Safety Purposes as Allowed or Required by Law:
    • To prevent or reduce a serious, immediate threat to the health or safety of a person or the public.
    • To public health or legal authorities
    • To protect public health and safety
    • To prevent or control disease, injury, or disability
    • To report vital statistics such as birth or deaths
  • To Report Suspected Abuse or Neglect of a child or dependent adult to public authorities.
  • To Correctional Institutions if you are in jail or prison, as necessary for your health and the health and safety of others.
  • For Law Enforcement Purposes such as when your therapist receives a subpoena, court order, or other legal process, or you are the victim of a crime.
  • For Health and Safety Oversight Activities. For example, your therapist may share health information with the Department of Health.
  • For Disaster Relief Purposes. For example, Your therapist may share information with disaster relief agencies to assist in notification of your condition to family or others.
  • For Work-Related Conditions That Could Affect Employee Health. For example, an employer may ask your provider(s) to assess health risk on a job site.
  • In the Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court order.
  • To the Military Authorities of U.S. and Foreign Military Personnel. For example, the law may require health care providers to provide information necessary to a military mission.

Other Uses and Disclosures of Protected Health Information

  • Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization

Effective Date 4/14/2003
Revised Date 2/17/2009

Notice of HIPPA Privacy Practices: Acknowledgment of Receipt of Notice of HIPPA Privacy Practices

Your therapist _____________________________will keep a record of the health care services he/she provides you. You may ask to see and copy that record. Your therapist will not disclose your record to others unless you direct him/her to do so or unless the law authorizes or compels him/her to do so. You may also ask to correct your record. You may get more information about this by contacting your therapist at his/her office telephone.

The Notice of HIPPA Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

By my signature below I acknowledge that I have reviewed the Notice of HIPPA Privacy Practices, and have had an opportunity to discuss any questions I may have.

Patient or legally authorized individual signature

Printed name if signed on behalf of the patient
Relationship (parent, legal guardian, etc.)

This form will be retained in your medical record. Last Update: 02/17/09