We have a legal responsibility under the laws of the United States and the state of Washington to keep your health information private. Part of our responsibility is to give you this notice about our privacy practices. Another part of our responsibility is to follow the practices in this notice.

This notice takes effect on April 14, 2003 and will be in effect until we replace it.

We have the right to change any of these privacy practices as long as those changes are permitted or required by law.

Any changes in our privacy practices will effect how we protect the privacy of your health information. This includes health information we will receive about you or that we create here at Samaritan Center of Puget Sound. These changes could also effect how we protect the privacy of any of your health information we had before the changes.

When we make any of these changes, we will also change this notice and give you a copy of the new notice. When you are finished reading this notice, you may request a copy of it at no charge to you.

If you request a copy of this notice at any time in the future, we will give you a copy at no charge to you.

If you have any questions or concerns about the material in this document, please ask us for assistance which we will provide at no additional charge to you.

Here are some examples of how we use and disclose information about your health information. Section I: Permissible uses and disclosures without your written authorization.

We may use or disclose your health information without your written authorization, excluding Psychotherapy Notes as described in Section II, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.

1. To your physician or other healthcare provider who is also treating you.
2. To anyone on our staff involved in your treatment program.
3. To any person required by federal, state, or local laws to have lawful access to your treatment program.
4. To receive payment from a third party payer for services we provide for you.
5. To our own staff in connection with our Center’s operations. Examples of these include, but are not limited to the following: evaluating the effectiveness of our staff, supervising our staff, improving the quality of our services, meeting accreditation standards, and in connection with licensing, credentialing, or certification activities.
6. To a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, we will give you an opportunity to object. If you object, or are not present, or are incapable of responding, we may use our professional judgment, in light of the nature of the emergency, to go ahead and use or disclose your health information in your best interest at that time. In so doing, we will only use or disclose the aspects your health information that are necessary to respond to the emergency.
7. When required or permitted to do so by law. For example, to appropriate authorities if your therapist reasonably believes that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. In addition, to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access your health information; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions or otherwise as authorized by law

We will not use your health information in any of our Center’s marketing, development, public relations, or related activities without your written authorization. We cannot use or disclose your health information in any ways other than those described in this notice unless you give us written permission.

Section II

With written permission: We may use or disclose your health information to anyone you give us written authorization to have your health information, for any reason you want. You may revoke this authorization in writing anytime you want. When you revoke an authorization it will only effect your health information from that point on.

Psychotherapy Notes: Notes recorded by your therapist documenting the contents of a counseling session with you ("Psychotherapy Notes") are not part of your health in information. They will be used only by your therapist and will not otherwise be used or disclosed without your written authorization.

As a client of Samaritan Center of Puget Sound, you have these important rights:

1. With limited exceptions, you can make a written request to inspect your health information that is maintained by us for our use.
2. You can ask us for photocopies of the information in part “A” above.
3. We will charge you $0.10 per page for making these photocopies.
4. You have a right to a copy of this notice at no charge.
5. You can make a written request to have us communicate with you about your health information by alternative means, at an alternative location. (An example would be if your primary language is not spoken at this Center, and we are treating a child of whom you have lawful custody.) Your written request must specify the alternative means and location.
6. You can make a written request that we place other restrictions on the ways we use or disclose your health information. We may deny any or all of your requested restrictions. If we agree to these restrictions, we will abide by them in all situations except those which, in our professional judgment, constitute an emergency.
7. You can make a written request that we amend the information in part “A” above.
8. If we approve your written amendment, we will change our records accordingly. We will also notify anyone else who may have received this information, and anyone else of your choosing.
9. If we deny your amendment, you can place a written statement in our records disagreeing with our denial of your request.
10. You may make a written request that we provide you with a list of those occasions where we or our business associates disclosed your health information for purposes other than treatment, payment, or our Center’s operations. This can go back as far as six years, but not before April 14, 2003.
11. If you request the accounting in “J” above more than once in a 12 month period we may charge you a fee based on our actual costs of tabulating these disclosures.
12. 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 complain to us in writing to the following person:

Compliance Officer:

Rev. Michael Rogers, LMFT
Telephone: (206) 526-2266, x329
Fax: (206) 527-1009
E-mail: MRogers@samaritanps.org

Address:

Samaritan Center of Puget Sound
564 NE Ravenna Blvd.
Seattle, WA 98115

13. You may also submit a written complaint to the United States Department of Health and Human Services. We will provide you with that address upon written request.

Terms Important in Understanding the HIPAA Privacy Rule

Health Information:

Any information, whether oral or recorded in any form, created or used by health care professionals or health care entities.

Individually Identifiable Health Information: A subset of Health Information that either identifies the individual or that can be used to identify the individual.

Protected Health Information (PHI)

Individually Identifiable Health Information becomes Protected Health Information when it is transmitted or maintained in any form or medium. More specifically, PHI is information that relates to the past, present or future physical or mental health condition of an individual; or the past, present or future payment for the provision of health care to individual; and that identifies the individual or could reasonably be used to identify the individual.

Psychotherapy Notes

Notes recorded in any medium by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or group, joint or family counseling session, and that are separated from the rest of the individual’s medical record.

Use and Disclosure

The privacy rule defines “use” as the sharing, employment, application, utilization, examination or analysis of individually identifiable health information within an entity that maintains such information.

The privacy rule defines a “disclosure” as the release, transfer, provision or access to, or divulging in nay other manner of information outside the entity holding the information.

The definition of the privacy rule specifically excludes information pertaining to medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests and any summary of the following: diagnosis, functional status, the treatment plan, symptoms, prognosis and process to date