Railroad in yellow grass

Privacy and Information Access Policy

How health information may be used and disclosed, and how you can get access to your own information.


  • PHI – Protected health information (Wikipedia)

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 policy applies to all of the records of your care generated by this mental health care practice and will tell you about the ways in which health information about you may be used and disclosed. The policy also describes your rights to the health information kept about you, and describes certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

  • Make sure that protected health information (“PHI”) that identifies you is kept private.
  • Provide you with an overview of my legal duties and privacy practices with respect to health information.
  • Follow the terms of the policy that is currently in effect.

The terms of this policy can change. Such changes will apply to all information I have about you. The new policy will be available upon request, in my office, and on my website.

How may health information about you be used and disclosed

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.

Treatment, Payment and 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 protected health information 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 personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

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 your child 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.

Certain uses and disclosures require your authorization

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:

  1. For my use in treating you.
  2. 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.
  3. For my use in defending myself in legal proceedings instituted by you.
  4. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
  5. Required by law and the use or disclosure is limited to the requirements of such law.
  6. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
  7. Required by a coroner who is performing duties authorized by law.
  8. Required to help avert a serious threat to the health and safety of others.

Marketing Purposes

As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

Sale of PHI

As a psychotherapist, I will not sell your PHI in the regular course of my business.

Certain uses and disclosures do not require your authorization

  1. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
  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.
  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, although my preference is to obtain an Authorization from you before doing so.
  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 counter-intelligence 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. 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.

Certain uses and disclosures require you to have the opportunity to object

Disclosures to family, friends and others

I may provide your PHI to a family member, friend, or another person that you indicate is involved in your care or the payment for your care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

Your rights in respect to your PHI

Request for limits on the use and disclosure of your PHI

Ask of 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.

Request restrictions for out-of-pocket expenses paid for In full

You have the right to request restrictions on disclosures 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.

Choose how to receive PHI communications

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.

See and obtain copies of your PHI

Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 15 days of receiving your written request.

Correct 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.

Obtain an overview of previous disclosures of your PHI

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, or for which you provided me with an Authorization. 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.

Obtain a copy of this policy

You have the right get a paper copy of this policy, and you have the right to get a copy of this policy by e-mail. And, even if you have agreed to receive this policy via e-mail, you also have the right to request a paper copy of it.

Request for release of information

The form

Download, fill out and return the official form.

Methods for returning a filled out form

  • If you are comfortable sending the form via a non-secure method, you may email it to
  • If you have access to the client portal, you may request this form to fill out electronically here and click “I’m an Existing Client”.
  • You can fax the form to 503-506-0699.
  • You can mail the form to Quo Vadis Wellness LLC, 1380 Hines St SE, Salem, OR 97302.
  • Email for alternative ways to send the form via secure means.