9085 East Mineral Circle | Suite 235 | Centennial, Colorado 80112 | Phone 720.299.8342 | Email

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This document contains information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides privacy protections and client rights with regard to the use and disclosure of your protected health information for the purposes of treatment, payment, and health care operations.  If you have any questions about the information contained in this document, please ask and I will be happy to answer them for you.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION (INCLUDING MENTAL HEALTH INFORMATION) ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

I respect my clients’ confidentiality and only release information in accordance with state and federal laws and the ethics of the psychology profession.  This notice describes my policies related to the use and disclosure of clients’ health information.

Use and Disclosure of Protected Health Information
Providing treatment services, collecting payment, and conducting healthcare operations are necessary activities for quality care.  I use and disclose the minimum necessary health information about you for these purposes, as allowed by state and federal law.

1.) Treatment:  I may use and disclose health information to provide, manage, and/or coordinate care and to consult with other professionals.  For example, I may share relevant information to facilitate appropriate emergency coverage by another professional in my absence. 

2.) Payment:  I may use and disclose your health information to obtain payment for services that I provide to you.  For example, I may share information to verify insurance and coverage and to process claims and collect fees.

3.) Healthcare Operations: I may use and disclose your health information as part of my internal healthcare operations.  For example, I may share information for the purpose of reviewing treatment procedures and records to assure quality, for training purposes, and for licensing and/or business activities. 

Other Uses and Information Disclosed Without Your Consent
In compliance with state and federal law, the following information may be disclosed without your consent:

1.) Mandated Reporting:  I may disclose health information about you related to the suspicion of child and/or elder neglect and/or abuse.

2.) Emergencies:  In emergency situations, I may disclose health information to prevent serious harm and/or death to yourself or others.

3.) Criminal Activity and/or Danger to Others:  I may disclose health information if a crime is committed on premises or against any personnel/staff, or if I believe there is 
someone who is in immediate danger.

4.) Appointment Scheduling/Client Contact:  I may use information you provide to contact you to schedule or remind you of appointments or to discuss treatment services.

5.) National Security, Intelligence Activities, and Protective Services to the President and Others:  I may disclose health information to authorized federal officers as authorized by law in order to protect the President or other national figures, or in cases of national security.

6.) Judicial and Administrative Proceedings:  I may disclose your health information in the course of judicial or administrative proceedings in response to a valid court order or other lawful process. 

Client Rights

1.) Right to Inspect and Copy:  You have a right to look at or get copies of your health information, with limited exceptions (i.e., psychotherapy notes).  Your request must be made in writing.  If you request a copy of your record, a reasonable charge may be made for costs incurred.

2.) Right to Amend:  You have the right to request that I amend your health information.  Your request must be made in writing, and it must explain why the information should be amended.  I have the right to deny your request if I believe the information contained in your record to be accurate and complete.  If denied, you have the right to file a disagreement statement.

3.) Right to Accounting Disclosures:  You have the right to receive a list of instances in which your health information has been disclosed for purposes other than treatment, payment, or healthcare operations.  This accounting does not include disclosures made to you or disclosures pursuant to a signed authorization to release information.

4.) Right to Request Restrictions:  You have a right to request a restriction or limitation on the health information used or disclosed about you.  For example, you may request that information not be disclosed to an insurance carrier, in which case you would be responsible for payment in full for services provided.  Your request must be made in writing.  While I am not obligated to agree to your request, I will consider the request very seriously.  If I agree to the restriction/limitation, I will abide by our agreement unless the information is needed in an emergency or required by law (for examples, please see the section above entitled, Other Uses and Information Disclosed Without Your Consent).

5.) Right to Request Confidential Communications:  You have the right to request that I contact you regarding health matters in a certain way or at a certain location.  For example, you may request that I only contact you through your cell phone number, or only at work.  I will make every attempt to accommodate reasonable requests.

6.) Right to Obtain a Paper Copy of this Notice/Changes in Notice:  You have the right to receive a paper copy of this notice and any amended notice.  I reserve the right to change my privacy practices provided such changes are permitted by applicable law.  Before the effective date of a material change, however, I will make a new notice available to you at my place of practice. 

8.) Right to Release your Health Information:  You have the right to request that certain health information be released at your request by signing an authorization to release information.  You may revoke a written authorization for release of information at any time; this request must be made in writing, and will be effective only for disclosures that have not already been completed. 

7.) Right to Complain:  If you believe your privacy rights have been violated, you have the right to file a complaint with me, or you may file a complaint with the United States Department of Health and Human Services.  No retaliation will be made against you if you choose to file a complaint. 

This notice is effective as of October 1, 2005.  Current edition as of August 16, 2018.

I understand and agree to all of the above information.  A copy of this information has been given to me for my records.
 

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Client (or Guardian) Signature                                                      Date

________________________________________________________________
Client (or Guardian) Printed Name                                                Date

________________________________________________________________
Dr. Jennifer Ritchie-Goodline, Psy.D.                                            Date
 

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Colorado Licensed Clinical Psychologist License #2741.  © Copyright 2006-2018 by Dr. Jennifer Ritchie-Goodline.  All Rights Reserved.

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