THIS NOTICE DESCRIBES HOW MEDICAL [INCLUDING MENTAL HEALTH] INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. During the process of providing services to you, the provider will obtain, record, and use mental health and medical information about you that is protected health information. Ordinarily, that information is confidential and will not be used or disclosed, except as described below.


A. General Uses and Disclosures Not Requiring the Client's Consent. The provider will use and disclose protected health information in following ways.

1.         Treatment. Treatment refers to the provision, coordination, or management of health care [including mental health care] and related services by one or more health care providers. For example, the provider will use your information to plan your course of treatment. As to other examples, the provider may consult with professional colleagues or ask professional colleagues to cover calls or the practice for the provider and will provide the information necessary to complete those tasks.

2. Payment. Payment refers to the activities undertaken by a health care provider [including a mental health provider] to obtain or provide reimbursement for the provision of health care. The provider will use your information to develop accounts receivable information, bill you, and with your consent, provide information to your insurance company or other third party payer for services provided. The information provided to insurers and other third party payers may include information that identifies you, as well as your diagnosis, type of service, date of service, provider name/identifier, and other information about your condition and treatment. If you are covered by Medicaid, information will be provided to the State of Colorado's Medicaid program, including but not limited to your treatment, condition, diagnosis, and services received.

3.         Health Care Operations. Health Care Operations refers to activities undertaken by the provider that are regular functions of management and administrative activities of the practice. For example, the provider may use or disclose your health information in the monitoring of service quality, staff evaluation, and obtaining legal services.

4.         Contacting the Client. The provider may contact you to remind you of appointments and to tell you about treatments or other services that might be of benefit to you.

5. Required by Law. The provider will disclose protected health information when required by law or necessary for health care oversight. This includes, but is not limited to: (a) reporting child abuse or neglect; (b) when court ordered to release information; (c) when there is a legal duty to warn or take action regarding imminent danger to others; (d) when the client is a danger to self or others or gravely disabled; (e) when a coroner is investigating the client's death; or (f) to health oversight agencies for oversight activities authorized by law and necessary for the oversight of the health care system, government health care benefit programs, or regulatory compliance.

6.         Crimes on the premises or observed by the provider. Crimes that are observed by the provider or the provider's staff, crimes that are directed toward the provider or the provider's staff, or crimes that occur on the premises will be reported to law enforcement.

7. Business Associates. Some of the functions of the provider may be provided by contracts with business associates. For example, some of the billing, legal, auditing, and practice management services may be provided by contracting with outside entities to perform those services. In those situations, protected health information will be provided to those contractors as is needed to perform their contracted tasks. Business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.

8.         Research. The provider may use or disclose protected health information for research purposes if the relevant limitations of the Federal HIPAA Privacy Regulation are followed. 45 CFR 164.512(i).

9. Involuntary Clients. Information regarding clients who are being treated involuntarily, pursuant to law, will be shared with other treatment providers, legal entities, third party payers and others, as necessary to provide the care and management coordination needed.

10. Family Members. Except for certain minors, incompetent clients, or involuntary clients, protected health information cannot be provided to family members without the client's consent. In situations where family members are present during a discussion with the client, and it can be reasonably inferred from the circumstances that the client does not object, information may be disclosed in the course of that discussion. However, if the client objects, protected health information will not be disclosed.

11. Emergencies. In life threatening emergencies the provider will disclose information necessary to avoid serious harm or death.

B. Client Authorization or Release of Information. The provider may not use or disclose protected health information in any other way without a signed authorization or release of information. When you sign an authorization, or a release of information, it may later be revoked, provided that the revocation is in writing. The revocation will apply, except to the extent the provider has already taken action in reliance thereon.


A. Access to Protected Health Information. You have the right to inspect and obtain a copy of the protected health information the provider has regarding you, in the designated record set. However, you do not have the right to inspect or obtain a copy of psychotherapy notes. There are other limitations to this right, which will be provided to you at the time of your request, if any such limitation applies. To make a request, ask your therapist.

B. Amendment of Your Record. You have the right to request that the provider amend your protected health information. The provider is not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions, which will be provided to you at the time of your request, if relevant, along with the appeal process available to you. To make a request, ask your therapist.

C. Accounting of Disclosures. You have the right to receive an accounting of certain disclosures the provider has made regarding your protected health information. However, that accounting does not include disclosures that were made for the purpose of treatment, payment, or health care operations. In addition, the accounting does not include disclosures made to you, disclosures made pursuant to a signed Authorization, or disclosures made prior to April 14, 2003. There are other exceptions that will be provided to you, should you request an accounting. To make a request, ask your therapist.

D.        Additional Restrictions. You have the right to request additional restrictions on the use or disclosure of your health information. The provider does not have to agree to that request, and there are certain limits to any restriction, which will be provided to you at the time of your request. To make a request, ask your therapist.

E. Alternative Means of Receiving Confidential Communications. You have the right to request that you receive communications of protected health information from the provider by alternative means or at alternative locations. For example, if you do not want the provider to mail bills or other materials to your home, you can request that this information be sent to another address. There are limitations to the granting of such requests, which will be provided to you at the time of the request process. To make a request, ask your therapist.

F. Copy of this Notice. You have a right to obtain another copy of this Notice upon request.

Copyright 2003Laurence B. James Not to be distributed outside of an authorized organization and not to be used by any person or organization without written permission from L.James.



A.           Privacy Laws. The provider is required by State and Federal law to maintain the privacy of protected health information. In addition, the provider is required by law to provide clients with notice of the provider's legal duties and privacy practices with respect to protected health information. That is the purpose of this Notice.

B. Terms of the Notice and Changes to the Notice. The provider is required to abide by the terms of this Notice, or any amended Notice that may follow. The provider reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that it maintains. When the Notice is revised, the revised Notice will be posted at the provider's service delivery sites and will be available upon request.

C. Complaints Regarding Privacy Rights. If you believe the provider has violated your privacy rights, you have the right to complain to the provider. Your therapist is the person designated within the practice to receive your complaints. You also have the right to complain to the United States Secretary of Health and Human Services by sending your complaint to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 515F, HHH Bldg., Washington, D.C. 20201. It is the policy of the provider that there will be no retaliation for your filing of such complaints.

D. Additional Information. If you desire additional information about your privacy rights, ask your therapist.


Client's Signature ________________________________ Date ______________


Signature:        M.A., LMFT                  Date: ____________

Notice is effective August, 2014.

Phone number (719) 471-1225

[Written by Frank Bennett, Ph.D. and Laurence James, Psy.D., JD.J