Shelley Fields, M.A., LMFT

Notice of Privacy Practices

My practice follows professional standards and laws to protect your privacy. Federal laws require us to provide you with a notice of our privacy practices.

This notices describes how you individual identifiable information may be used or disclosed. Also, this notice describes how you may get access to your individual identifiable information that is maintained by my practice. Please read this notice and ask any questions you have on how your information is kept confidential.

Ways I Can Use and Disclose Information WITHOUT Your Permission

Typically, I will ask for your written permission or authorization to share or obtain information with others. However, I may use and disclose information about you in the following circumstances:

2. Treatment: I may use your information and disclose it to manage or coordinate treatment provided to you. For example, I may share information with another therapist or your physician to coordinate services.

3. Payment: I may used and disclose necessary information about you to obtain payment for my services. For example, this information could include information that your health insurance plan may require before it approves or pays for treatment services I recommend for you.

4. Health Care Operations: I may need to use or disclose information for my practice actives. Examples of these activities include: Compliance activities to ensure I am properly following policies, procedures, laws, regulations, and professional standards.

I may use or disclose information about you in several other circumstances in which you do not have an opportunity to agree or object. These situations include:

1. Required by Law: I may need to disclose information for judicial or other administrative proceedings. For example, I may need to disclose information in response to a court order.

2. Abuse or Neglect: I am required to disclose information if I believe that you or a family member have been a victim or abuse or neglect OR if you or a family member is abusing or neglecting another person.

3. Danger to Self or Others: I am required to take steps to prevent you from harming yourself or another person.

4. Law Enforcement: Law enforcement purposes may include:

• Legal processes required by law

• Limited information requests for identification and location purposes

pertaining to victims of a crime

• In the event a crime occurs on our premises

5. Public Health: I may be required by law to report health related information for public health activities.

5. Other circumstances: Although not typically encountered in my practice, there are other situations where I may disclose information without your written authorization. Examples of these circumstances include information on veterans or national security activities.

For any reason other than those listed above, I will ask you for your written authorization before I can use or disclose any information about you. Also, any authorization can be canceled any time in writing. (If you tell me you are canceling an authorization, I will have you sign a request during the current or next visit.) If cancelled, I will no longer disclose information that was allowed under that specific authorization.

Important!: Therapy notes have special protection and I will not release or disclose therapy notes without your permission to do so, except when required by law.

I have a specific policy on the use and disclosure of therapy notes. This policy can be shared with you if you request.

Your Rights About Your Private Identifiable Information

1. Request Restrictions: You may request further restrictions on our uses and disclosures of your information. We may not be able to agree to all requested restrictions. Please let us know if you want specific restrictions on your information.

2. Different Ways to Communicate: Typically I will communicate by mailing or phoning your residence. I will occasionally communicate with you by e-mail. However, you may prefer a different way for us to contact you. For example, you may or may not want messages left on your voice mail or answering machine. You may ask me to contact you at a specific address or phone. Please note that cell phones and e-mail may not offer confidentiality or privacy.

3. Right to See and Copy Information: You may see and receive copies of the information maintained in your designated record. I may charge for copying your designated record. Please note that therapy notes are not part of your designated record. Because therapy notes are not part of your designated record, you may not have access to your therapy notes. If you want to see your therapy notes, please speak with me.

4. Right to Request Amendment of Your Information: You may request that information about you may be amended or changed. We may deny your request if we did not create the information (it was obtained from another source.) Also, we may deny your request if we believe the information is correct. Denials will be written and will describe your rights for further review. If we agree to amend, we will make reasonable efforts to share with any person who may have received your information that it needs amending. Please ask us if you want to amend your information that we maintain in your designated record.

5. Listing of Disclosures I Have Made: You may request a list of disclosures of your information for up to the last six (6) years, made after April 14, 2003 (when the Federal Privacy Rule took effect) or disclosures related to your treatment, payment or my practice operations, and those disclosures required by law. Ask me if you desire a list of disclosures.

6. Copy of This Notice: You may request a copy of this notice at any time. A copy is available at my practice sites. It is also posted on my WebPage.

7. You May File a Complaint About My Privacy Practice: If you think I have violated your privacy rights described in this notice, you may complain to me or you may send a written complaint to the Secretary, Department of Health and Human Services.