Therapy & Rates

Notice of Privacy Practices

Your Information. Your rights. My responsibilities.

As your therapist, I am required by law to maintain the privacy of protected health information. Protected Health Information (“PHI”) includes any individually identifiable information about your physical or mental health, the health care you receive, and the payment for your health care. This notice describes how your PHI may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you.

1. Get a paper copy of your medical record. You can ask to see or get a paper copy of your medical record and other health information I have about you for as long as the PHI is maintained in the record. Ask me how to do this. I will provide a copy or, where clinically appropriate, a summary of your health information, usually within 30 days of your request. I may charge a reasonable, cost-based fee.

2. Ask me to correct your medical record. You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this. I may say “no” to your request, but I’ll tell you why in writing within 60 days.

3. Request confidential communications. You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address. I will say “yes” to all reasonable requests.

4. Ask me to limit what I use or share. You can ask me not to use or share certain health information for treatment, payment, or our operations. I am not required to agree to your request, and I may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or our operations with your health insurer. I will say “yes” unless a law requires me to share that information.

5. Get a list of those with whom I’ve shared information. You can ask for a list (accounting) of the times I’ve shared your health information. I will include only the disclosures for which you have neither provided authorization nor consent. I’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

6. Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.

7. Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person may be able to exercise your rights and make choices about your health information. If you have appointed a health care proxy, and your proxy has been properly activated by a physician. I will make sure the person has this authority and can act for you before I take any action.

8. File a complaint if you feel your rights are violated. You can complain if you feel I have violated your rights by contacting the privacy official named above. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. I will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell me your choices about what I share. If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions.

1. You have both the right and choice to tell me to share information with your family, close friends, or others involved in your care. This requires your written authorization, which may be revoked at any time, except to the extent that I have already made a use or disclosure based upon your authorization.

2. In these cases, I never share your information unless you give me written permission: a) marketing purposes, and b) sale of your information.

My Uses and Disclosures

How do I typically use or share your health information? I typically use or share your health information in the following ways.

1. Treat you. I use health information about you to provide, coordinate and manage your treatment and related services.

2. Run my practice. I can use and share your health information to run my practice, and improve your care.

3. Bill for your services. I can use and share your health information to bill and get payment for the treatment services provided to you.

Your authorization or consent is not required in the following circumstances:

1. Emergency situations. If you are not able to tell me your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information to assist relevant authorized personnel in the event of a medical or mental health emergency.

2. Serious Threat to Health or Safety. If you communicate to me an explicit threat to kill or inflict serious bodily injury upon an identified person and you have the apparent intent and ability to carry out the threat, I must take reasonable precautions. Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization. I must also do so if I know you have a history of physical violence and I believe there is a clear and present danger that you will attempt to kill or inflict bodily injury upon an identified person. Furthermore, if you present a clear and present danger to yourself (for example, suicidal ideation or impaired judgment due to mental illness) and refuse to accept further appropriate treatment, and I have a reasonable basis to believe that you can be committed to a hospital, I must seek said commitment and may contact members of your family or other individuals if it would assist in protecting you.

3. Child abuse. If I, in my professional capacity, have reasonable cause to believe that a minor child is suffering physical or emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk of harm to the child’s health or welfare (including sexual abuse), or from neglect, including malnutrition, I must immediately report such condition to the Massachusetts Department of Children and Families.

4. Elder abuse. If I have reasonable cause to believe that an elderly person (age 60 or older) is suffering from or has died as a result of abuse, I must immediately make a report to the Massachusetts Department of Elder Affairs.

5. Abuse of a disabled person. If I have reasonable cause to suspect abuse of an adult (ages 18-59) with mental or physical disabilities, I must immediately make a report to the Massachusetts Disabled Persons Protection Commission.

6. Health Oversight. Health oversight agencies have the power, when necessary, to request relevant records, should I be the focus of an inquiry.

7. Judicial or Administrative Proceedings. If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and I will not release information without written authorization from you or your legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case. The privilege also does not apply in certain proceedings to dispense with consent to the adoption of a child, to provide for the care and protection of a child or to place a child in foster care. Nor does the privilege apply to any proceeding where I have acquired the information while conducting an investigation.

8. Worker’s Compensation. If you file a workers’ compensation claim, your records relevant to that claim may be disclosed for purposes of the worker’s compensation proceeding if ordered by the presiding officer.

9. Specialized Government Functions. I may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

10. Legal proceeding or complaint against me. If you initiate a legal proceeding or submit a complaint against me.

How else can I use or share your health information?

I am allowed or required to share your information in other ways. I have to meet many conditions in the law before I can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

1. In the event of your death. I will disclose or not disclose your information based on your preferences. However, I also have to follow federal and state legal requirements, which may require disclosure. The personal representative of your estate (administrator or executor of your will) or your duly authorized legal representative can still have access to your records based on state law requirements.

2. Respond to lawsuits and legal actions. I can share health information about you in response to a court or administrative order. I can also share health information about you in response to a subpoena if you have first received notice that the subpoena will be issued and have not objected to the subpoena within the time period for objections under state law.

3. Comply with law enforcement. I may be required to disclose your PHI for authorized law enforcement purposes or with an authorized law enforcement official but only to the extent provided by law or regulation.

My Responsibilities

1. I am required by law to maintain the privacy and security of your protected health information.

2. I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

3. I must follow the duties and privacy practices described in this notice and give you a copy of it.

4. I will not use or share your information other than as described here unless you tell me I can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind. If you tell me in writing I can use or share your information and more than one person is receiving mental health counseling along with you, each such person must also agree in writing that I can use or share information about him/her or information obtained from him/her or information obtained in his/her presence.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This Notice

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

Effective date of notice: April 1, 2021

Know Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.  

What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs,  such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to  pay the entire bill if you see a provider or visit a health care facility that isn’t in your health  plan’s network.  

“Out-of-network” describes providers and facilities that haven’t signed a contract with your  health plan. Out-of-network providers may be permitted to bill you for the difference between  what your plan agreed to pay and the full amount charged for a service. This is called “balance  billing.” This amount is likely more than in-network costs for the same service and might not  count toward your annual out-of-pocket limit. 

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is  involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.  

You are protected from balance billing for: 

• Emergency services: If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance  billed for these emergency services. This includes services you may get after you’re in stable  condition, unless you give written consent and give up your protections not to be balanced  billed for these post-stabilization services.  

• Certain services at an in-network hospital or ambulatory surgical center: When you get services from an in-network hospital or ambulatory surgical center, certain  providers there may be out-of-network. In these cases, the most those providers may bill you is  your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia,  pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist  services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.  If you get other services at these in-network facilities, out-of-network providers can’t balance  bill you, unless you give written consent and give up your protections.  

You’re never required to give up your protections from balance billing. You also  aren’t required to get care out-of-network. You can choose a provider or facility  in your plan’s network.  

When balance billing isn’t allowed, you also have the following protections: 

• You are only responsible for paying your share of the cost (like the copayments,  coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly. 

• Your health plan generally must: *Cover emergency services without requiring you to get approval for services in  advance (prior authorization). 

*Cover emergency services by out-of-network providers. 

*Base what you owe the provider or facility (cost-sharing) on what it would pay an  in-network provider or facility and show that amount in your explanation of  benefits. 

*Count any amount you pay for emergency services or out-of-pocket limit. 

If you believe you’ve been wrongly billed, you may contact the No Surprises Help Desk at 1-800-985-3059. 

Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.