HIPAA Notice

Changes to the Terms of This Notice


We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Effective: May 1, 2016

Your Rights

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

Get an electronic or paper copy of your medical record

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

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

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

Ask us to limit what we use or share
  • You can ask us not to use or share certain health information for treatment, payment, or our operations.
  • We are not required to agree to your request, and we 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 us not to share that information for the purpose of payment or our operations with your health insurer.
  • We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information
  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’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.

Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated
  • You can complain if you feel we have violated your rights by contacting us using the information on page 1.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
  • We will not retaliate against you for filing a complaint.

Your Choices

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

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
  • Include your information in a hospital directory
  • Contact you for fundraising efforts
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when

In these cases we never share your information unless you give us written permission:
  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

In the case of fundraising:
  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways.
Treat you

  • We can use your health information and share it with other professionals who are treating you.
EXAMPLE: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization
  • We can use and share your health information to run our practice, improve your care, and contact you when necessary.
EXAMPLE: We use health information about you to manage your treatment and services.

Bill for your services
  • We can use and share your health information to bill and get payment from health plans or other entities.
EXAMPLE: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues
  • We can share health information about you for certain situations such as:
    • Preventing disease
    • Helping with product recalls
    • Reporting adverse reactions to medications
    • Reporting suspected abuse, neglect, or domestic violence
    • Preventing or reducing a serious threat to anyone’s health or safety

Do research
  • We can use or share your information for health research.

Comply with the law
  • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
  • We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director
  • We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
  • We can use or share health information about you:
    • For workers’ compensation claims
    • For law enforcement purposes or with a law enforcement official
    • With health oversight agencies for activities authorized by law
    • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions
  • We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Connecticut Law requires psychotherapists to use or disclose phi without your consent or authorization in the following circumstances (I will inform you of such a request ahead of time if possible):
  1. Abuse and/or neglect: Suspicion of abuse or neglect of a child must be reported to Child and Family Protective Services. or a law enforcement agency. Similarly, I am required to report domestic abuse or the abuse neglect of an aged person or incapacitated adult.
  2. Serious threat to health or safety: Connecticut law requires of counselors to protect other members of society from harmful actions by their patients. Intended voiced threat or direct harm to another person requires me to take steps to protect such individuals by either warning the potential victim (or the victim’s guardian) or by notifying a law enforcement agency.
  3. Workers compensation: If you file a workers’ compensation claim, I am required by law, upon request, to submit relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
  4. Judicial or administrative proceedings: Under Connecticut law, exceptions to therapist-patient privilege may apply if you are involved in a court proceeding in which your mental health is a relevant issue. This means that others may issue a subpoena seeking both diagnostic and treatment information as evidence in a court case. If I receive such a subpoena, I will inform you immediately and, with your authorization, will cooperate with your attorney in order to protect such information if possible. An authorization is not required however, if disclosure of your medical records is ordered, for example, by the court.
  5. Health oversight: The Connecticut Department of Health has the power, when necessary, to subpoena relevant records should I, for example, become the focus of an inquiry.

CT LPC privilege statement

Under Section 52-146s of the Connecticut General Statutes, the confidential nature of your treatment is protected from any disclosure by Artistic Healings. This privilege applies to all communications, whether oral or written, between you or a member of your family and Artistic Healings. Only after written consent by you may Artistic Healings disclose any communications you have had with us. This consent may be withdrawn in writing by you at any time.
There are certain exceptions where Artistic Healings does not need written consent to disclose your communications:

  1. If the communications are made in the course of a mental health assessment ordered by a judicial body. In this case, you would have been informed prior to the beginning of the communications that they would not remain privileged.
  2. If the communications are the subject of a civil proceeding where you have introduced mental health as an element of a claim or defense, or where they are the subject of a probate proceeding.
  3. If the disclosure of the communications are required under any provision of the Connecticut General Statutes.
  4. If Artistic Healings believes in good faith that the failure to disclose such communication presents a clear and present danger to the health or safety of any individual.
  5. If Artistic Healings believes in good faith that there is risk of imminent personal injury to the you or to other individuals or risk of imminent injury to the property of other individuals.
  6. If Artistic Healings knows or believes in good faith that you have engaged in child abuse, abuse of an elderly individual, or abuse of an individual who is disabled or incompetent.
  7. If Artistic Healings makes a claim for collection of fees for services rendered under policies and procedures specified elsewhere in this Informed Consent, we may disclose your name and address, and the amount of the fees, to individuals or agencies involved in such collection. The disclosure will be limited to the following: (A) that you received professional counseling, (B) the dates of such services, and (C) a general description of the types of services.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

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

LPC: CT003188 • NPI: 1063845188

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