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Terms and Policy

Notice of Privacy Practices
Notice of Privacy Practices to Protect Your Health Information


The Counseling Office of Nikki Penn, LPC, LMFT is committed to protecting the privacy of client personal and health information. This notice explains our clinic’s privacy practices and your rights as mandated by the Health Insurance Portability and Accountability Act (HIPAA).

To help you understand this document we have defined some key terms below:

• “PHI” refers to Protected Health Information in your health record that could identify you.
• “Treatment is when we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist.
• “Payment” is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
• “Health Care Operations” are activities that relate to the performance and operation of the Clinic. 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 the Clinic such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of the Clinic, such as releasing, transferring, or providing access to information about you to other parties.
• “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.
• “Psychotherapy Notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record.

How We Protect Your Health Information

We protect your health information by:

• Treating all of your health information that we have as confidential.
• Restricting access to your health information to those who need to have access in order to provide our service to you.
• Maintaining physical, electronic, and procedural safeguards to comply with federal and state regulations.
• Requiring everyone who conducts activity in the Clinic to receive HIPAA training.

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

If you have consented to receive services from our clinic, we may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes without your written authorization.

Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes outside of treatment, payment, or health care operations only with your appropriate authorization. In instances when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your Psychotherapy Notes. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time provided that each revocation is in writing. However, you may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

Uses and Disclosures with Neither Consent nor Authorization

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

• Child Abuse – If we believe that a child is a victim of child abuse or neglect, we must report this belief to the appropriate authorities.
• Abuse of an Elder Person – If we believe or have reason to believe that an individual is an endangered adult, we must report this belief to the appropriate authorities.
• Health Oversight Activities – If there is an investigation into the counseling practice, then the therapist is required to disclose PHI upon receipt of a subpoena.
• Judicial and Administrative Proceedings – If the patient is involved in a court proceeding and a request is made for information about the professional services we provided you and/or the records thereof, such information is privileged under state law, and we will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege may not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
• Serious Threat to Health or Safety – If you communicate to us an actual threat of violence to cause serious injury or death against a reasonably identifiable victim or victims or if you evidence conduct or make statements indicating an imminent danger that you will use physical violence or use other means to cause serious personal injury or death to others, we may take the appropriate steps to prevent that harm from occurring. If we have reason to believe that you present an imminent, serious risk of physical harm or death to yourself, we may need to disclose information in order to protect you. In both cases, we will only disclose what we feel is the minimum amount of information necessary.
• Worker’s Compensation – We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

Patient’s Rights and Therapist’s Duties

Patient’s Rights:

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are 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.
• Right to Inspect and Copy Your PHI – You have the right to inspect and/or obtain a copy 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. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.
• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we 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, we 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 us upon request, even if you have agreed to receive the notice electronically.

Therapist’s Duties:

• We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
• We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
• If we revise our policies and procedures we will update this Notice and post the changes in our waiting room. You may request a copy of the Notice at any time.


If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Nikki Penn, LPC, LMFT at 870-793-0071.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

Effective Date, Restrictions, and Changes to Privacy Policy

HIPAA went into effect April 14, 2003. This document was revised on January 1, 2014
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