899 Logan St, Suite 311
Denver, CO 80203
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA)
requires all health care records and other individually identifiable
health information (protected health information) used or disclosed to
us in any form, whether electronically, on paper, or orally, be kept
confidential. This federal law gives you, the patient, significant new
rights to understand and control how your health information is used.
HIPAA provides penalties for covered entities that misuse personal
health information. As required by HIPAA, we have prepared this
explanation of how we are required to maintain the privacy of your
health information and how we may use and disclose your health
Without specific written authorization, we are permitted to use and
disclose your health care records for the purposes of treatment,
payment and health care operations.
I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is
personal. I am committed to protecting health information about you.
I create a record of the care and services you receive from me. I need
this record to provide you with quality care and to comply with certain
legal requirements. This notice applies to all of the records of your
care generated by this practice. This notice will tell you about the
ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you,
and describe certain obligations I have regarding the use and
disclosure of your health information. I am required by law to:
• Make sure that protected health information (“PHI”) that
identifies you is kept private.
• Give you this notice of my legal duties and privacy practices
with respect to health information.
• Follow the terms of the notice that is currently in effect.
• I can change the terms of this Notice, and such changes will
apply to all information I have about you. The new Notice will be
available upon request, in my office, and on my website.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT
The following categories describe different ways that I use and
disclose health information. For each category of uses or disclosures
I will explain what I mean and try to give some examples. Not every
use or disclosure in a category will be listed. However, all of the ways
I am permitted to use and disclose information will fall within one of
For Treatment Payment, or Health Care Operations: Federal privacy
rules (regulations) allow health care providers who have direct
treatment relationship with the patient/client to use or disclose the
patient/client’s personal health information without the patient’s
written authorization, to carry out the health care provider’s own
treatment, payment or health care operations. I may also disclose
your protected health information for the treatment activities of any
health care provider. This too can be done without your written
authorization. For example, if a health care provider were to consult
with another licensed health care provider about your condition, we
would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the
health care provider in diagnosis and treatment of your condition.
Disclosures for treatment purposes are not limited to the minimum
necessary standard. Because other health care providers need
access to the full record and/or full and complete information in order
to provide quality care. The word “treatment” includes, among other
things, the coordination and management of health care providers
with a third party, consultations between health care providers and
referrals of a patient for health care from one health care provider to
another. Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose
health information in response to a court or administrative order. I
may also disclose health information about your child in response to
a subpoena, discovery request, or other lawful process by someone
else involved in the dispute, but only if efforts have been made to tell
you about the request or to obtain an order protecting the information
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR
1. Session Notes: I do keep “Session notes” and any use or
disclosure of such notes requires your Authorization unless the
use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising associates to help them
improve their clinical skills.
c. For my use in defending myself in legal proceedings instituted
d. For use by the Secretary of Health and Human Services to
investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the
requirements of such law.
f. Required by law for certain health oversight activities
pertaining to the originator of the session notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and
safety of others.
2. Marketing Purposes. As a health care provider, I will not use or
disclose your PHI for marketing purposes.
3. Sale of PHI. As a health care provider, I will not sell your PHI in
the regular course of my business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR
Subject to certain limitations in the law, I can use and disclose your
PHI without your Authorization for the following reasons:
1. When disclosure is required by state or federal law, and the use
or disclosure complies with and is limited to the relevant
requirements of such law.
2. For public health activities, including reporting suspected child,
elder, or dependent adult abuse, or preventing or reducing a
serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and
4. For judicial and administrative proceedings, including
responding to a court or administrative order, although my
preference is to obtain an Authorization from you before doing
5. For law enforcement purposes, including reporting crimes
occurring on my premises.
6. To coroners or medical examiners, when such individuals are
performing duties authorized by law. 7. For research purposes, including studying and comparing the
patients who received one form of care versus those who
received another form of care for the same condition.
8. Specialized government functions, including, ensuring the
proper execution of military missions; protecting the President
of the United States; conducting intelligence or
counterintelligence operations; or, helping to ensure the safety
of those working within or housed in correctional institutions.
9. For workers’ compensation purposes. Although my preference
is to obtain an Authorization from you, I may provide your PHI in
order to comply with workers’ compensation laws.
10. Appointment reminders and health related benefits or services. I
may use and disclose your PHI to contact you to remind you
that you have an appointment with me. I may also use and
disclose your PHI to tell you about treatment alternatives, or
other health care services or benefits that I offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE
THE OPPORTUNITY TO OBJECT.
1. Disclosures to family, friends, or others. I may provide your PHI to a family
member, friend, or other person that you indicate is involved in your care
or the payment for your health care, unless you object in whole or in part.
The opportunity to consent may be obtained retroactively in emergency
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR
1. The Right to Request Limits on Uses and Disclosures of Your
PHI. You have the right to ask me not to use or disclose certain
PHI for treatment, payment, or health care operations purposes.
I am not required to agree to your request, and I may say “no” if
I believe it would affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses
Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health
care operations purposes if the PHI pertains solely to a healthcare item or a health care service that you have paid for out-of-
pocket in full. 3. The Right to Choose How I Send PHI to You. You have the right
to ask me to contact you in a specific way (for example, home
or office phone) or to send mail to a different address, and I will
agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than
“session notes,” you have the right to get an electronic or paper
copy of your medical record and other information that I have
about you. I will provide you with a copy of your record, or a
summary of it, if you agree to receive a summary, within 30 days
of receiving your written request, and I may charge a
reasonable, cost based fee for doing so.
5. The Right to Get a List of the Disclosures I Have Made.You have
the right to request a list of instances in which I have disclosed
your PHI for purposes other than treatment, payment, or health
care operations, or for which you provided me with an
Authorization. I will respond to your request for an accounting of
disclosures within 60 days of receiving your request. The list I
will give you will include disclosures made in the last six years
unless you request a shorter time. I will provide the list to you at
no charge, but if you make more than one request in the same
year, I will charge you a reasonable cost based fee for each
6. The Right to Correct or Update Your PHI. If you believe that
there is a mistake in your PHI, or that a piece of important
information is missing from your PHI, you have the right to
request that I correct the existing information or add the missing
information. I may say “no” to your request, but I will tell you
why in writing within 60 days of receiving your request. 7. The Right to Get a Paper or Electronic Copy of this Notice. You
have the right get a paper copy of this Notice, and you have the
right to get a copy of this notice by e-mail. And, even if you have
agreed to receive this Notice via e-mail, you also have the right
to request a paper copy of it.
EFFECTIVE DATE OF THIS NOTICE
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996
(HIPAA), you have certain rights regarding the use and disclosure of
your protected health information. By checking the box below, you
are acknowledging that you have received a copy of HIPAA Notice of