top of page



I. Uses and Disclosures for Treatment, Payment, and Health Care Operations The law allows that I may use and disclose your protected health information (PHI) without your specific consent or authorization for the following reasons (other reasons appear later in this document.): For Treatment or health care operations – I may use and disclose your PHI in the process of assuring quality care. For example, medical information may be used to review treatment and services in order to evaluate the quality of your care. Your name need not be used. For payment – I may use and disclose your PHI so that treatment and services may be billed and payment collected from you, an insurance company or a third party. For example, protected health information such as your name, address, and office visit date, codes identifying diagnosis and treatment may be sent to your insurance company for payment.


II. Uses and Disclosures Requiring Authorization I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. 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 each revocation is in writing. You may not revoke authorizations to the extent that (1) I have relied on that authorization, or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.


III. Uses and Disclosures with Neither Consent nor Authorization I may use or disclose PHI without your consent or authorization in the following circumstance:  Child Abuse: If I know or have reason to believe a child is being neglected or physically or sexually abused, or has been neglected or physically or sexually abused within the preceding three years, I must immediately report the information to the local welfare agency, policy or sheriff’s department.  Adult and Domestic Abuse: If I have reason to believe that a vulnerable adult is being or has been maltreated, or if I have knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained, I must immediately report the information to the appropriate agency in this county. I may also report the information to a law enforcement agency. “Vulnerable adult” means a person who, regardless of residence or whether any type of service is received, possesses a physical or mental infirmity or other physical, mental or emotional dysfunction:


(i) that impairs the individual’s ability to provide adequately for the individual’s own care without assistance, including the provision of food, shelter, clothing, health care, or supervision; and


(ii) because of the dysfunction or infirmity and the need for assistance, the individual has an impaired ability to protect the individual from maltreatment.  Health Oversight Activities: A state licensing board may subpoena records from me if they are relevant to an investigation it is conducting.  Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is privileged under state law and I must not release this information without written authorization from you or your legally appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. I will inform you in advance if this is the case.  Serious threat to Health or Safety: If you communicate a specific, serious threat of physical violence against a specific, clearly identified or identifiable potential victim, I must make reasonable efforts to communicate this threat to the potential victim or to a law enforcement agency. I must also do so if a member of your family or someone who knows you well has reason to believe you are capable of and will carry out the threat. I may also disclose information about you necessary to protect you from a threat to commit suicide.  Worker’s Compensation: If you file a worker’s compensation claim, a release of information from me to your employer, insurer, the Department of Labor and industry or you will not need your prior approval.


IV. Client’s Rights and Pastoral Counselor’s Duties Client’s Right:  Right to request restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am 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. (For example, you may not want a family member to know that you are seeing me. At your request, I will contact you at another address or by other means.)  Right to inspect and copy: You have the right to inspect or obtain a copy (or both) of PHI (and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. Details of the request procedure: The request must be in writing. You will receive a response from me within 30 days of my receiving your request. If I feel I must deny your request I will give you, in writing, the reasons for the denial. If you wish to have my denial reviewed, I will provide a copy of your PHI to another qualified health professional for his/her review. If you ask for copies of your PHI I will charge you not more than $.25 per page. I may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as the cost, in advance.  Right amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. Details of the request procedure: The request must be in writing. You will receive a response within 60 days of my receipt of your request. I may deny your request if I find that the PHI is

(a) correct and complete,

(b) forbidden to be disclosed,

(c) not part of my records,

or (d) written by someone other than me. My denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and my denial be attached to any future disclosures of you PHI. If I approve of your request, I will make the change(s) to your PHI. I will tell you that the changes have been made, and I will advise all others who need to know about the changes to your PHI.  Right to an accounting: You generally have a right to receive an accounting of disclosure of PHI for which you have neither provided consent nor authorization. The list will not include uses of disclosures to which you have already consented, i.e., those for treatment, payment, or health care operations, sent directly to you or to your family. Neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. After April 15, 2003, disclosure records will be held for eight years. Details of the request procedure: The request must be in writing. I will respond within 60 days of receiving your request. The list I will give you will include disclosures made in the previous eight years (the first eight year period being 2003-2011) unless you indicate a shorter period. The list will include the date of the disclosure, to whom the PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no cost, unless you make more than one request in the same year, in which case I will charge you a reasonable sum based on a set fee for each additional request.  Right to a paper copy: You have the right to obtain a paper copy of this notice. Pastoral counselor’s duties:  I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.  I reserve the right to change the privacy policies and practices as described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.  If I revise my policies and procedures, I will give you a new copy in person or by mail.


V. Complaints If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, I request that you first communicate that complaint directly to me. If you are not satisfied with my response, you may send a written complaint to: Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue S.W. Room 509F, HHH Building Washington, D.C. 20201

bottom of page