POST STORM THERAPY
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY. YOU MAY HAVE ADDITIONAL RIGHTS UNDER STATE AND LOCAL
LAW. PLEASE SEEK LEGAL COUNSEL FROM AN ATTORNEY LICENSED IN YOUR STATE IF
YOU HAVE QUESTIONS REGARDING YOUR RIGHTS TO HEALTH CARE INFORMATION.
EFFECTIVE DATE OF THIS NOTICE THIS NOTICE WENT INTO EFFECT ON 8/1/2025
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE UNDER THE HEALTH
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HEREAFTER, “HIPAA”),
YOU HAVE CERTAIN RIGHTS REGARDING THE USE AND DISCLOSURE OF YOUR
PROTECTED HEALTH INFORMATION (HEREAFTER, “PHI”). 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 MENTAL HEALTH CARE 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 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 THE 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 YOU: 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 THE CATEGORIES. 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 PHI FOR THE TREATMENT ACTIVITIES OF
ANY HEALTH CARE PROVIDER. THIS TOO CAN BE DONE WITHOUT YOUR WRITTEN
AUTHORIZATION. FOR EXAMPLE, IF A CLINICIAN WERE TO CONSULT WITH ANOTHER
LICENSED HEALTH CARE PROVIDER ABOUT YOUR CONDITION, WE WOULD BE
PERMITTED TO USE AND DISCLOSE YOUR PHI, WHICH IS OTHERWISE CONFIDENTIAL,
IN ORDER TO ASSIST THE CLINICIAN IN DIAGNOSIS AND TREATMENT OF YOUR HEALTH
CONDITION. I MAY ALSO USE YOUR PHI FOR OPERATIONS PURPOSES, INCLUDING
SENDING YOU APPOINTMENT REMINDERS, BILLING INVOICES AND OTHER
DOCUMENTATION. PAGE 1 DISCLOSURES FOR TREATMENT PURPOSES ARE NOT
LIMITED TO THE MINIMUM NECESSARY STANDARD. BECAUSE THERAPISTS AND 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 YOU OR YOUR MINOR CHILD(REN) 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 REQUESTED. III. CERTAIN USES
AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: 1. PSYCHOTHERAPY NOTES. I DO
KEEP “PSYCHOTHERAPY NOTES” AS THAT TERM IS DEFINED IN 45 CFR § 164.501, 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 MENTAL HEALTH PRACTITIONERS TO HELP THEM IMPROVE
THEIR SKILLS IN GROUP, JOINT, FAMILY, OR INDIVIDUAL COUNSELING OR THERAPY. C.
FOR MY USE IN DEFENDING MYSELF IN LEGAL PROCEEDINGS INSTITUTED BY YOU. D.
FOR USE BY THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES
(HHS) 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 PSYCHOTHERAPY 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. I WILL
NOT USE OR DISCLOSE YOUR PHI FOR MARKETING PURPOSES WITHOUT YOUR PRIOR
WRITTEN CONSENT. FOR EXAMPLE, IF I REQUEST A REVIEW FROM YOU AND PLAN TO
SHARE THE REVIEW PUBLICALLY ONLINE OR ELSEWHERE TO ADVERTISE MY SERVICES
OR MY PRACTICE, I WILL PROVIDE YOU WITH A RELEASE FORM AND HIPAA
AUTHORIZATION. THE HIPAA AUTHORIZATION IS REQUIRED IN THE INSTANCE THAT
YOUR REVIEW CONTAINS PHI (I.E., YOUR NAME, THE DATE OF THE SERVICE YOU
RECEIVED, THE KIND OF TREATMENT YOU ARE SEEKING OR OTHER PERSONAL HEALTH
DETAILS). BECAUSE YOU MAY NOT REALIZE WHICH INFORMATION YOU PROVIDE IS
CONSIDERED “PHI,” I WILL SEND YOU A HIPAA AUTHORIZATION AND REQUEST YOUR
SIGNATURE REGARDLESS OF THE CONTENT OF YOUR REVIEW. ONCE YOU COMPLETE
THE HIPAA AUTHORIZATION, I WILL HAVE THE LEGAL RIGHT TO USE YOUR REVIEW FOR
ADVERTISING AND MARKETING PURPOSES, EVEN IF IT CONTAINS PHI. YOU MAY
WITHDRAW THIS CONSENT AT ANY TIME BY SUBMITTING A WRITTEN REQUEST TO ME
VIA THE EMAIL ADDRESS I KEEP ON FILE OR VIA CERTIFIED MAIL TO MY ADDRESS.
ONCE I HAVE RECEIVED YOUR WRITTEN WITHDRAWAL OF CONSENT, I WILL REMOVE
YOUR REVIEW FROM MY WEBSITE AND FROM ANY OTHER PLACES WHERE I HAVE
POSTED IT. I CANNOT GUARANTEE THAT OTHERS WHO MAY HAVE COPIED YOUR
REVIEW FROM MY WEBSITE OR FROM OTHER LOCATIONS WILL ALSO REMOVE THE
REVIEW. THIS IS A RISK THAT I WANT YOU TO BE AWARE OF, SHOULD YOU GIVE ME
PERMISSION TO POST YOUR REVIEW. 3. SALE OF PHI. I WILL NOT SELL YOUR PHI. IV.
USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION. SUBJECT TO
CERTAIN LIMITATIONS IN THE LAW, I CAN USE AND DISCLOSE YOUR PHI WITHOUT
YOUR AUTHORIZATION FOR THE FOLLOWING REASONS. I HAVE TO MEET CERTAIN
LEGAL CONDITIONS BEFORE I CAN SHARE YOUR INFORMATION FOR THESE PURPOSES:
1. 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. 2. 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. PAGE 2 3. 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. 4. FOR HEALTH
OVERSIGHT ACTIVITIES, INCLUDING AUDITS AND INVESTIGATIONS. 5. FOR JUDICIAL
AND ADMINISTRATIVE PROCEEDINGS, INCLUDING RESPONDING TO A COURT OR
ADMINISTRATIVE ORDER OR SUBPOENA, ALTHOUGH MY PREFERENCE IS TO OBTAIN AN
AUTHORIZATION FROM YOU BEFORE DOING SO IF I AM SO ALLOWED BY THE COURT
OR ADMINISTRATIVE OFFICIALS. 6. FOR LAW ENFORCEMENT PURPOSES, INCLUDING
REPORTING CRIMES OCCURRING ON MY PREMISES. 7. TO CORONERS OR MEDICAL
EXAMINERS, WHEN SUCH INDIVIDUALS ARE PERFORMING DUTIES AUTHORIZED BY
LAW. 8. FOR RESEARCH PURPOSES, INCLUDING STUDYING AND COMPARING THE
MENTAL HEALTH OF PATIENTS WHO RECEIVED ONE FORM OF THERAPY VERSUS THOSE
WHO RECEIVED ANOTHER FORM OF THERAPY FOR THE SAME CONDITION. 9.
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. 10. 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. 11.
FOR ORGAN AND TISSUE DONATION REQUESTS. V. CERTAIN USES AND DISCLOSURES
REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT. DISCLOSURES TO FAMILY,
FRIENDS, OR OTHERS: YOU HAVE THE RIGHT AND CHOICE TO TELL ME THAT I MAY
PROVIDE YOUR PHI TO A FAMILY MEMBER, FRIEND, OR OTHER PERSON WHOM YOU
INDICATE IS INVOLVED IN YOUR CARE OR THE PAYMENT FOR YOUR HEALTH CARE, OR
TO SHARE YOU INFORMATION IN A DISASTER RELIEF SITUATION. THE OPPORTUNITY TO
CONSENT MAY BE OBTAINED RETROACTIVELY IN EMERGENCY SITUATIONS TO
MITIGATE A SERIOUS AND IMMEDIATE THREAT TO HEALTH OR SAFETY OR IF YOU ARE
UNCONSCIOUS. VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI: 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 THE DISCLOSURE
OF YOUR PHI TO HEALTH PLANS FOR PAYMENT OR HEALTH CARE OPERATIONS
PURPOSES IF THE PHI PERTAINS SOLELY TO A HEALTH CARE 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 IN LIMITED CIRCUMSTANCES, YOU
HAVE THE RIGHT TO GET AN ELECTRONIC OR PAPER COPY OF YOUR MEDICAL RECORD
AND OTHER INFORMATION THAT I HAVE ABOUT YOU. ASK US HOW TO DO THIS. I WILL
PROVIDE YOU WITH A COPY OF YOUR RECORD, OR IF YOU AGREE, A SUMMARY OF IT,
WITHIN 30 DAYS OF RECEIVING YOUR WRITTEN REQUEST. 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, ANS OTHER DISCLOSURES (SUCH AS ANY
YOU ASK ME TO MAKE). ASK ME HOW TO DO THIS. 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 ADDITIONAL REQUEST.
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. PAGE 3 7. THE RIGHT TO GET A PAPER OR ELECTRONIC COPY OF THIS
NOTICE. YOU HAVE THE RIGHT TO GET A PAPER COPY OF THIS NOTICE, AND YOU HAVE
THE RIGHT TO GET A COPY OF THIS NOTICE BY EMAIL. AND, EVEN IF YOU HAVE AGREED
TO RECEIVE THIS NOTICE VIA EMAIL, YOU ALSO HAVE THE RIGHT TO REQUEST A PAPER
COPY OF IT. 8. THE RIGHT TO CHOOSE SOMEONE TO ACT FOR YOU. IF YOU HAVE GIVEN
SOMEONE MEDICAL POWER OF ATTORNEY OR IF SOMEONE IS YOUR LEGAL GUARDIAN,
THAT PERSON CAN MAKE CHOICES ABOUT YOUR HEALTH INFORMATION. 9. THE RIGHT
TO REVOKE AN AUTHORIZATION. 10. THE RIGHT TO OPT OUT OF COMMUNICATIONS
AND FUNDRAISING FROM OUR ORGANIZATION. 11. THE RIGHT TO FILE A COMPLAINT.
YOU CAN FILE A COMPLAINT IF YOU FEEL I HAVE VIOLATED YOUR RIGHTS BY
CONTACTING ME USING THE INFORMATION ON PAGE ONE OR BY FILING A COMPLAINT
WITH THE HHS OFFICE FOR CIVIL RIGHTS LOCATED AT 200 INDEPENDENCE AVENUE,
S.W., WASHINGTON D.C. 20201, CALLING HHS AT (877) 696-6775, OR BY VISITING
WWW.HHS.GOV/OCR/PRIVACY/HIPAA/COMPLAINTS. I WILL NOT RETALIATE AGAINST
YOU FOR FILING A COMPLAINT. VII. CHANGES TO THIS NOTICE I CAN CHANGE THE
TERMS OF THIS NOTICE, AND SUCH CHANGES WILL APPLY TO ALL THE INFORMATION I
HAVE ABOUT YOU. THE NEW NOTICE WILL BE AVAILABLE UPON REQUEST, IN MY OFFICE
AND ON MY WEBSITE. PAGE 4