Sara Klinzman, MA, LMHC dba Klinzman & Associates, LLC
1820 Black Lake Blvd SW, Suite 101, Olympia, WA 98512
360-350-2288
sara@saraklinzman.com
HIPAA NOTICE OF PRIVACY PRACTICES

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

THE EFFECTIVE DATE OF THIS UPDATED POLICY IS SEPTEMBER 23, 2013.

I ONLY RELEASE INFORMATION IN ACCORDANCE WITH STATE AND FEDERAL LAWS AND THE ETHICS OF THE COUNSELING PROFESSION. Protected Health Information(PHI) means individually identifiable health information that is transmitted by electronic media, maintained in any medium described in the definition of electronic media, or transmitted or maintained in any other form or medium.
THIS NOTICE DESCRIBES MY POLICIES RELATED TO THE USE AND DISCLOSURE OF CLIENT’S HEALTHCARE INFORMATION.
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) FOR THE PURPOSES OF PROVIDING SERVICES, PROVIDING TREATMENT SERVICES, COLLECTING PAYMENT AND CONDUCTING HEALTHCARE OPERATIONS ARE NECESSARY ACTIVITIES FOR QUALITY CARE. STATE AND FEDERAL LAWS ALLOW ME TO USE AND DISCLOSE YOUR HEALTH INFORMATION FOR THESE PURPOSES.
I MAY USE AND SHARE YOUR INFORMATION FOR:
TREATMENT
• Provide, manage or coordinate care
• Consultants
• Referral sources
PAYMENT—Use and disclose health information to:
• Verify insurance and coverage
• Process claims and collect fees
HEALTHCARE OPERATIONS-Use and disclose health information for:
• Review of treatment procedures
• Review of business activities
• Certification
• Staff Training
• Compliance and licensing activities
OTHER USES AND DISCLOSURES
• Per your authorization
Legally permitted with opportunity to object
• Others involved in your healthcare: family member or friend that you have identified
• Medical emergency
• Communication barriers
Legally permitted with no opportunity to object
• Mandated reporting of suspected abuse, neglect or domestic violence
• Legal proceedings: in response to subpoena or other lawful process
• Public health
• Criminal Damage
• Appointment scheduling
• Treatment alternatives
• Coroners, funeral directors
• Military activity and National Security
• FDA: report adverse events, product defects

SPECIALLY PROTECTED INFORMATION
Special laws may restrict the use and disclosure of medical information related to mental health conditions, substance abuse, sexually transmitted diseases and HIV/AIDS. When your personal health information falls under these special protections, you will be asked to provide the appropriate authorizations to comply with federal and sate laws such as: Uniform Health Care Information Act, Sexually Transmitted diseases, Drug and Alcohol Abuse Records, Mental Health Services for Minors, Communicable and Certain Other Diseases Confidentiality, Confidentiality of Alcohol and Drug Abuse patients.
If your health information is needed for any other reason that has not been described in this notice you will be asked for written authorization to disclose information, you can revoke the authorization at a later time to stop any future use of disclosure.

CLIENT RIGHTS:
Health and billing records created and stored are the property of Sara Klinzman, MA, LMHC dba Klinzman & Associates, LLC. The protected health information in it, however, belongs to you. You have the right to:
RECEIVE, READ, AND ASK QUESTIONS ABOUT THIS NOTICE
Request and receive an electronic or paper copy of the most current Notice of Privacy Practices

RIGHT TO RELEASE YOUR MEDICAL RECORDS
• Written authorization to release records
• Right to revoke or cancel release in writing.
• Revocation is not valid to the extent that you have acted in reliance on such previous authorizations

RIGHT TO INSPECT AND COPY YOUR MEDICAL BILLING RECORDS
• Right to inspect and copy records
• Counselor may deny this request
• Charges for copying, mailing, etc

RIGHT TO ADD INFORMATION OR AMEND YOUR MEDICAL RECORDS
• May request to amend record
• I May deny the request, but will tell you why in writing within 60 days
• If denied, you have the right to file disagreement statement
• Disagreement statement and your response will be filed in the record
• Amendment request must be in writing
RIGHT TO ACCOUNTING OF DISCLOSURES
• You can ask for a list of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with and why

Exceptions:
• Disclosure for treatment, payment or healthcare operations
• Disclosures pursuant to a signed release
• Disclosures made to client
• Disclosures for national security or law enforcement

RIGHT TO REQUEST RESTRICTIONS ON USES AND DISCLOSURE OF YOUR HEALTHCARE INFORMATION
• Must be in writing
• I am not obligated to agree
• You can ask not to use or share certain health information for treatment payment, however, I am not required to agree to your request and I may say “no” if it would affect your care.
• If you pay for service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will say “yes” unless a law requires me to share that information.

RIGHT TO COMPLAIN
• Please contact me first: Sara Klinzman, MA, LMHC 360-350-2288
• If not satisfied, right to complain to the Washington Dept. of Health and Human Services: 510 4th Avenue, Ste 404, Seattle, WA 98119. You may also file a complaint with the U.S. Secretary of Health and Human Services.
• Your right to file a complaint is respected and you will not face retaliation.

RIGHT TO RECEIVE CHANGES IN POLICY
• May request any future changes
• Request to privacy officer


I NEVER USE YOUR INFORMATION FOR MARKETING AND WILL NEVER SELL YOUR INFORMATION.