Notice of Privacy Practices

This notice describes how Protected Health Information (PHI) about you may be used and disclosed and how you can get access to this information.  Please review it carefully.

If you have any questions about this notice, please discuss them with me prior to or proceeding your session or call 510.393.9441 to arrange a time.

Who Will Follow This Notice?

Your health information is personal, and I am committed to protecting this information. I create a record of the care and services you receive. I need this record to provide you with quality care and to comply with legal requirements. This notice describes my privacy practices and applies to all records of your care by me. Any individual authorized to enter information into your clinical record and anyone using or disclosing Protected Health Information follows these privacy practices. This notice explains the ways I may use and disclose health information. It also describes your rights and my obligations regarding the use and disclosure of PHI. My obligations include the following:

  • Assure health information that identifies you is kept private (with certain allowed exceptions).
  • Give you this notice of privacy practices.
  • Follow the terms of the notice that is currently in effect.

Disclosing Your Health Information

Applicable confidentiality laws are followed. No health information about you will be released without your written authorization, unless it is permitted by law in the following ways:

For Treatment

I may use health information to provide you with treatment or services. I may disclose information to other health care providers and staff who are involved in your care and treatment. This information is used to plan your treatment services. It is also used to document progress, events, plans of care, observations, and evaluation of care and treatment. Health information may be provided to consultants, diagnostic services, or other providers involved in your care.

For Payment

I may use and disclose health information about you so that the treatment and services you receive may be billed to a third party such as Medicare, Oregon Health Plan, Continuous Care Organizations (CCO), Health Maintenance Organizations (HMOs), County/Authority/Public Agencies, Insurance Companies, or to you or others who may be responsible for payment of your care.
At least some health information may be provided to the payee that identifies your demographic information, the diagnosis, and any additional health information needed to support the billing.

For Health Care Operations

I may use and disclose health information for health care operations. These uses and disclosures are necessary to make sure that all clients receive quality care. The information used for these purposes may include your health information, or it may be “de-identified” so that the key statistical information is included but it cannot be linked to you.

Health and Safety Risks

I may disclose health information to report the abuse or neglect of children, elders and dependent adults, the threat of violence to an identified target, or in a health care emergency when required or authorized by law.

As Required by Law, Emergency/Disaster, and Law Enforcement

I may release health information in the following situations:

  • to health oversight agencies for activities authorized by law, including surveys by the state, federal and other review agencies, as well as audits, investigations, inspections, and licensure.
  • in response to a court order, subpoena, warrant, summons or similar process.
  • to identify or locate a suspect, fugitive, material witness, or missing person.
  • in emergency circumstances regarding crimes.
  • to assist in an emergency or disaster.
  • to an entity assisting in a disaster so that your family can be notified about your condition, status, and location.
  • to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
  • to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
  • when required to do so by federal, state, or local law.

Your Rights Regarding Health Information

You have the following rights regarding health information:

Right to Inspect and Copy

You have the right to inspect and copy the health information used to make decisions about your treatment. To inspect and copy your health information, you must submit your request in writing. Your request to inspect and copy may, under certain circumstances, be denied. If denied access to health information, you may request a review of the denial by an independent practitioner. The outcome of that review will be provided to you.

Right to Amend

You have the right to request an amendment if you feel that your health information is incorrect or incomplete. Your request for amendment must be written. In addition, you must provide a reason that supports your request. Your request may be denied if it is incomplete or not in writing. You cannot amend information not created by me, is not part of health information that I maintain, is not part of the information which you are permitted to inspect and copy, or the information in the record is accurate and complete.

If your request is denied you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the addendum to be made part of your health record, it is attached to your records and included whenever disclosing the item or statement you believe to be incomplete or incorrect.

Right to Accounting of Disclosures

You have the right to request an “accounting of disclosures.”

Right to Request Restriction

You have the right to request a restriction or limitation on the health information used or disclosed about you for treatment, payment, or health care operations. I am not required to agree to your request. If I do agree, I will comply unless the information must be used to provide you with emergency treatment.

To request restrictions, you must submit your request in writing. In your request, you must tell me (1) what information you want to limit; (2) whether you want to limit my use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications

You have the right to request that I communicate with you about health matters in a certain way or at a certain location. For example, you may ask that I only contact you at work or by mail. I will not ask the reason for your request. I will accommodate all reasonable requests. You must make your request in writing. In your request, you must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice

You have the right to a paper copy of this notice and may request it at any time.

Changes to This Notice

I reserve the right to change this notice.


Anyone who thinks that a psychologist, or psychology resident has acted illegally, irresponsibly, or unprofessionally may file a complaint with:

Oregon Board of Psychology
3218 Pringle Road SE, Suite 130
Salem, Oregon 97302
FAX: 503-374-1904

Note: Everyone has the right to file a complaint without fear of harassment. You will not be penalized for filing a complaint.

If you believe we have violated any of your privacy rights, or you disagree with a decision we have made about any of your rights in this notice, you may send a written complaint:

Professional Practice, LLC
ATTN: Dragonfly BHC
PO Box 503010
White City, OR 97503-0813

You may also submit a written complaint to the United States Department of Health and Human Services at:

Office of Mental Health Services
Alcohol and Mental Health Division
500 Summer St. N.E. E86
Salem, OR 97301-1118

Governor’s Advocacy Office: 800.422.5238
Disability Rights Oregon: 800.452.1694

Other Uses of Health Information

To use or disclosure health information in a way that is not covered by this Notice, I will request and comply with your written permission. You may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or disclosure of your health information covered by that written authorization. You understand that I am unable to take back any disclosures I have already made with your permission, and that I am required to retain my records of the care that I provide to you.

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