Notice of Privacy Policies:

The Gottman Institute is an educational and training institute and does not provide treatment and is not bound by HIPAA laws and regulations.  However, we are making this information available for your benefit.

At the beginning of therapy, U.S. Federal HIPAA law requires that your independently practicing clinician present you with a notice of privacy policies similar to that presented in this document. Please be sure that you receive and sign such a document prior to proceeding with therapy.

I.          Uses and Disclosures for Treatment, Payment, and Health Care Operations

“Clinicians” may use or disclose your protected health information (PHI), for treatment, payment, and health care operations.

To help clarify these terms, here are some definitions:

• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment and Health Care Operations”
  • Treatment is when “Clinicians” provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when “Clinicians”consult with another health care provider, such as your family physician or another psychologist.
  • Payment is when “Clinicians”obtain reimbursement for your healthcare. Examples of payment are when “Clinicians”disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
  • Health Care Operations are activities that relate to the performance and operation of the “Clinicians”practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
  “Use” applies only to activities within the “Clinicians”office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of the “Clinicians”office, such as releasing, transferring, or providing access to information about you to other parties.

II.         Uses and Disclosures Requiring Authorization

“Clinicians”may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when “Clinicians”are asked for information for purposes outside of treatment, payment and health care operations, “Clinicians”will obtain an authorization from you before releasing this information. “Clinicians”will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes “Clinicians”have made about your conversation during a private, group, joint, or family counseling session, which “Clinicians”have kept separate from the rest of your medical record.These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) “Clinicians” have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

Uses and Disclosures with Neither Consent nor Authorization

“Clinicians” must disclose health care information about you without your authorization:

·         If the “Clinician” becomes aware that you may be abusing, exploiting or neglecting a child under age 18, a developmentally disabled person, or an elderly person, a report must be made to the appropriate authorities (RCW 26.44).

·         If you become a danger to others, “Clinicians”must protect the other person(s) and you by warning the other person(s) at risk and report the danger to the appropriate authorities (RCW 74.05.120).

·         If you become mentally ill and become unable to take care of your basic needs or become a danger to yourself or others and also refuse treatment, “Clinicians”mustreport your condition to the authorities (RCW 71.05).

·         If you tell the “Clinician” that you are suffering from HIV-related illness and do not have a physician providing for your care, “Clinicians”must report the identities of your IV drug using or sexual partner(s) to the local health care officer (WAC 248-100-072).

·         If a professional licensing board subpoenas the “Clinician” as part of its investigation, hearing or proceedings relating to the discipline, issuance or denial of licensure of state licensed psychologists, “Clinicians”must comply with its order and disclose your relevant mental health information (RCW 18.130.180).

·         If you are involved in a court proceeding and a request is made for information about the professional services that “Clinicians” have provided to you and the records thereof, such information is privileged under state law, and “Clinicians”will not release information without the written authorization of you or your legal representative, or a court order signed by a judge. 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.

·         If you file a worker’s compensation claim, with certain exceptions, “Clinicians” must make available, at any stage of the proceedings, all mental health information in “Clinicians”possession relevant to that particular injury in the opinion of your state’s Department of Labor and Industries, to your employer, your representative, and the Department of Labor and Industries upon request (RCW 51.36.110).

·         If the “Clinician” reasonably believe that disclosure will avoid or minimize an imminent danger to the health or safety of the patient or any other individual, I may disclose information to the extent a recipient needs to know to any person, including law enforcement (RCW 710.02.050).

III.       Patient’s Rights and ”Clinician's” Duties

Patient’s Rights:

·         Right to Refuse Evaluation or Treatment – You have the right to refuse evaluation or treatment any time.

·         Right to Change "Clinicians" – You have the right to change "Clinicians" or to receive a referral to another "Clinician".

·         Right to Raise Questions – You have the right to raise at any time, any question about the "Clinicain", the therapeutic approach and/or the progress of treatment.

·         Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, “Clinicians”are not required to agree to a restriction you request.

·         Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing the “Clinician”. Upon your request, “Clinicians”will send your bills to another address).

·         Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in “Clinicians”mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. “Clinicians”may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, “Clinicians”will discuss with you the details of the amendment process.

·         Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, “Clinicians”will discuss with you the details of the accounting process.

·         Right to a Paper Copy – You have the right to obtain a paper copy of the notice from the “Clinician”upon request, even if you have agreed to receive the notice electronically.

“Clinician's” Duties:

• “Clinicians”are required by law to maintain the privacy of PHI and to provide you with a notice of their legal duties and privacy practices with respect to PHI.
• “Clinicians”reserve the right to change the privacy policies and practices described in this notice. Unless “Clinicians”notify you of such changes, however, I am required to abide by the terms currently in effect.
• If “Clinicians”revise their policies and procedures, they will provide you with a copy of the revised notice via first class mail, or provide it to you during a session.

IV.      Complaints

If you are concerned that the “Clinician” has violated your privacy rights, or you disagree with a decision they have made about access to your records, you may contact them directly.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services, 2201 Sixth Ave., Suite 800, Seattle, WA98121.

V.          Effective Date and Changes to Privacy Policy

This notice will go into effect on ____________________. “Clinicians” reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that they maintain. “Clinicians” will provide you with a revised notice via first class mail, or provide it to you during a session.

Acknowledgement:

Certified Gottman Therapists ("Clinicians") are all licensed or certified therapists who practice independently in their state, province, or country and are not supervised by Drs. John or Julie Gottman or the Gottman Institute. However, each has been specifically trained by Drs. John and Julie Gottman to provide Gottman Method Couples Therapy.

I hereby acknowledge receiving a copy of this Notice of Privacy Policies

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Client Signature                                                         Date