NOTICE OF PRIVACY PRACTICES
| Dana Kovalchick, MA, LMHC Therapist for Individuals and Couples 2366 Eastlake Ave E, Suite 225, Seattle, WA 98102 206.419.0155 |
This notice describes how medical information about you may be used and disclosed and how
you can get access to this information. Please review it carefully and ask any questions.
Purpose
As your therapist, I am committed to protecting the privacy of you personal information. I am
also required by law to maintain this privacy and to provide you with this detailed notice of my
legal responsibilities and privacy practices relating to your personal healthcare information.
This is a legal document and therefore contains specific legal terms specified in federal law.
Record Keeping Practices
Standard practice requires me to keep an official record of your therapy process. Typically for
individuals, this includes a general description of your emotional or psychological functioning,
agreed upon treatment goals, a list of symptoms, medications, a description of therapeutic
progress, and sometimes a diagnosis. The content of your record is altered somewhat if I am
seeing you as a member of a couple or family.
Your Rights Relating to Your Personal Healthcare Information
I am required by law to maintain the privacy of your personal healthcare information and to
provide you with this document describing my legal duties and privacy practices with respect to
the information I hold about you. You also have the following rights:
• The right to control disclosure of your personal information and treatment records
through the state requirement of a signed authorization form that specifically describes the
content, recipient(s), and the duration of a release of your information by me.
• The right to request restriction on certain uses and disclosures.
You may ask me not to use or disclose any part of your personal information for purposes of
treatment, payment, or healthcare operations of my practice. You may also request that any
part of your personal information not be disclosed to your family member or friends who may
be involved in your care, or for notification purposes described in this notice. Your request –
made in writing – should state the specific restriction requested and to whom you want the
restriction to apply.
Please be advised that I am not required by law to agree to such requests for restrictions. If I
believe that it is in your best interest to make such disclosure, I will not honor your restriction
request, but will discuss this with you at the time of your request. If I do agree to honor our
request for a restriction, I may not use or disclose your personal information in violation of that
restriction.
• The right to receive confidential communications containing your personal information
from me by alternative means, or at an alternative address.
I will accommodate reasonable request if you prefer to receive information from me in an
alternative manner (non via US mail). In certain circumstances, I may also condition this
accommodation upon your providing information as to how payment for your sessions will be
handled, and/or for an alternative address or other method of contact. I will not request an
explanation from you regarding the basis for your request. Please make your request in
writing and deliver it to me personally or by mail.
• The right to inspect and obtain a copy of your official treatment record.
You have the right to receive and inspect a copy of your official treatment record (the
information I compile about your therapy that I consider in making treatment decisions about
you, plus your billing records – or as the federal government refers to it – a designated record
set), for as long as I maintain it. Please ask me about this, and send me a written request if
you choose to exercise this right.
You should understand also that there may be certain restrictions to this right. Depending on
certain uncommon circumstances, I may make a decision that disclosing your record to you
may not be in your best interest. In this type of circumstances, we might consider other
options, one of which might be to provide you with a summary version. Another option might
include my turning over your treatment record to another health care provider of your choice
who will accept responsibility to the decision to disclose it to you.
• The right to amend your official treatment record.
You have the right to request that I amend your official treatment record for as long as I
maintain your information. There may be instances in which I deny your request for such an
amendment, but if this occurs, you have the right to file a statement of disagreement with me,
and I am allowed to prepare a rebuttal to your statement and provide you a copy of any such
rebuttal – all of which will go into your official record. Please talk with me if you have any
questions about amending your official record.
• The right to receive an accounting of disclosure that have been made of your personal
healthcare information and/or official treatment records (or portions of that record).
This right applies to non-routine disclosures or those made for purposes other than treatment,
payment, or healthcare operations of my practice as described in this notice. It also excludes
disclosures I may have made to you or to family members or friends involved in your care, or
as directed by you in a specific written authorization for disclosure. The right to receive this
information is subject to certain exceptions, restrictions, and limitations. Please ask me or
make a written request for this accounting.
• The right to obtain a paper copy of my Notice of Privacy Practices upon request.
If you believe that your privacy rights have been violated by me, you may file a complaint with
the Secretary of Health and Human Services and/or to me verbally, or simply by a written
statement. You may ask me about further information regarding this complaint process. I will
not retaliate against you for filing such a complaint.
Required Uses and Disclosures of Your Official Therapy Record
I am required to make disclosures to you at your request, and when required to do so by the
Secretary of the Department of Health and Human Services to investigate or determine my
compliance with federal privacy regulations.
Possible Uses and Disclosures of Your Personal Information
Disclosures with your written permission:
With a limited number of exceptions, Washington State law requires me to obtain your written
permission prior to my disclosing any of your personal healthcare information. For example, if
it seems potentially productive for me to speak with your primary care physician, or you want
me to talk with your attorney, parent, etc, I must ask you to first sign a very specific release of
information that details what information can be shared, for what purposes, and the date upon
which your permission expires. If prior to that date you change your mind, you have the right
to withdraw your permission.
Disclosure without your written permission:
Incidental Disclosures – Unless otherwise directed by you, I may acknowledge you by first
name in my waiting room, by mailing statements to your home address, returning phone calls,
calling to discuss scheduling issues, etc. I will make every effort to be discreet, but if you have
any concerns, please discuss them with me.
Abuse or Neglect and Legal – I am legally required to break confidentiality by conveying
specific information to the appropriate recipients if you tell me about the abuse or neglect of a
child or vulnerable adult; if you convey information about the imminent harm directed either at
yourself or someone else; and in some circumstances, in response to a court order.
Operations of My Practice – I am permitted to release a limited amount of your personal
healthcare information (when necessary) without your specific permission for certain business-
related purposes such as accounting, billing, and legal services. In these cases, any outside
professional services will be contractually obligated to protect your privacy. Only the minimum
amount of you personal information necessary to accomplish a task will be released.
Other Disclosures – State and Federal privacy regulations allow me to use and disclose your
personal information in types of uncharacteristic circumstances listed below. You generally will
have the opportunity to object or agree to these uses or disclosures; however, if you are not
present or able to agree or object, I am permitted to use my professional judgment to
determine whether a disclosure is in your best interest. Under such circumstances, I will only
disclose information that is relevant to the situation.
• Others involved in your healthcare – to family members, close friends, or anyone else
you specify as being able to receive limited information relating to your healthcare.
• Disaster and Relief Efforts – to an authorized public or private entity.
• Emergency Treatment Situations – to authorized pubic or private emergency treatment
entities, such as a hospital or fire department emergency medical technicians.
• Required by law – to the extent that the use or disclosure is required by law, made in
compliance with the law, and limited to relevant and required information. You will be notified
of any such uses or disclosures.
o Public Health – to a public health authority permitted by law to collect or receive such
information (i.e. controlling disease, injury, disability).
o Communicable Diseases – health oversight agency authorized by law (investigations,
inspections, etc.).
o Legal Proceedings – judicial or administrative proceedings in response to a court order
and in some circumstances a subpoena, discovery request, or other lawful process.
o Law Enforcement – with appropriate legal processes – (i.e. limited information request
for identification and location purposes; pertaining to victims of a crime; suspicion that death
has occurred as a result of criminal activity; in the event that a crime occurs on the premises of
my practice; in medical emergencies that do not occur on my premises, and when it is not
suspected that a crime has occurred).
o National Security – to authorize federal officials for conducting national security and
intelligence activities, including for the protection services to the President or others legally
authorized.
o Workers’ Compensation – as authorized to comply with workers’ compensation laws and
other similar legally-established programs.
Changes to this Notice of Privacy Practices
I am required to abide by the terms of this Notice of Privacy Practices, but I am also permitted
to change the terms of this notice at any time. Once a revision is in use, it applies to all of your
personal healthcare information that I maintain whether or not you are still in treatment with
me. You may request a copy of my revised Notice of Privacy Practices at any of your
appointments, or ask that one be mailed or emailed to you by leaving me a message on my
voicemail.
