CHRISTIAN WOLFF, MA  Licensed Psychologist Associate/Consultant 820 NW 21st Avenue, Suite B / Portland, OR  97209 / christian@christianwolff.com Notice of Privacy Practices May 1, 2007 This notice describes how clinical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this notice, please do not hesitate to ask. WHO WILL FOLLOW THIS NOTICE This notice describes the privacy of information practices I follow in the delivery of my services as a Licensed Psychologist Associate. The practices described in this notice will also be followed by practitioners you consult with by telephone who provide call coverage for me if/when I am not available YOUR HEALTH INFORMATION This notice applies to the information and records I have about your health, health status, and the health care and services you receive at this office. I am required by law to give you this notice. It will tell you about the ways in which I may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU I must have your written, signed consent to use and disclose health information for the following purposes: For treatment. With your permission, I may use health information about you to provide you with clinical treatment or services. I may disclose health care information about you to doctors or other health care providers in order to coordinate your treatment. In some instances, various office personnel may have access to your information. Office personnel in health care settings have minimal access to your information. They have this access on a need-to-know basis and are also bound by privacy policies. For instance, an office records person may see a signed request for your records and would need to know your name in order to find the chart. Family members or friends may be involved in your treatment. With your permission, I may provide your information to them and receive information about you from them. For payment. I may use and disclose health care information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company, or a third party. It may also be necessary to tell your health plan about a treatment you are going to receive in order to obtain prior authorization for the delivery of a service, or to determine whether your plan will cover the treatment. For quality of care. In order to provide better service, I may discuss your information with other therapists or supervisors with whom I consult. Whenever identifiable information is disclosed, the privacy policies described here are in effect. Confidentiality is also governed by professional ethics. Appointment reminders. With your permission, I may contact you as a reminder that you have an appointment for treatment or clinical care at the office. I also may return messages to you and will presume that you wish for your messages to be returned. If I am uncertain about the amount of detail I may leave in a message, or with whom I may speak, I will act conservatively and only leave my name and number. You may revoke a signed consent at anytime by giving me written notice. Your revocation will be effective when I receive it, but will not apply to any of the uses and disclosures which occurred before that time. If you do revoke your consent, I will not be permitted to disclose your information for the purpose intended and treatment, treatment coordination, payment, or health operations may be disrupted. If clinically appropriate, treatment will continue. Revoking consent does not automatically mean that treatment must be discontinued. In some cases, it may be necessary to alter the course of treatment, and in still other cases, it may not be possible to continue. In such cases, I may choose to discontinue providing you with health care treatment and services. SPECIAL SITUATIONS I may use or disclose health care information about you without your permission for the following purpose, subject to all applicable legal requirements and limitations: To avert a serious threat to health or safety. I may use and disclose health information about you when necessary to prevent or respond to a serious threat to your health and safety, for the health and safety of the public, or the health and safety of another person. Required by law. I will disclose health information about you when required to do so by federal, state, or local law. *Please note: There are many other parties which may require you to provide them with information about your treatment. If my disclosure of your information is not required by law, I will not disclose it without your written consent. Examples of the parties which may require such information from you may include disability services, worker’s compensation, courts, etc. Although, these parties may legally require you to provide such information in order to proceed, in most cases, I will still need your permission for that information to be disclosed from the records that I keep. Other uses. For research, quality assurance, or clinical oversight, I may use your information in a way that does not identify you. OTHER USES AND DISCLOSURE OF HEALTH CARE INFORMATION Substance abuse and HIV. There are special laws which protect you regarding the disclosure of information about substance abuse and HIV. In addition to the written consent mentioned above, special consent must be obtained from you in order for me to disclose any information about you which involves substance abuse or HIV. Mail and electronic communication. Although I take every reasonable precaution and abide by professional standards, it is possible for communication to be intercepted. This includes postal mail, faxes, telephone calls, and e-mail. It is important that you inform me of any restrictions you would like me to honor in order to keep your information protected. YOUR RIGHTS REGARDING HEALTH CARE INFORMATION ABOUT YOU You have the following rights regarding health care information that I maintain about you: Right to inspect and copy. You have the right to inspect and copy your health information, such as clinical and billing records, that I use to make decisions about your care. You must submit a written request to me in order to inspect and/or copy your health care information. If you request a copy, I may charge a fee for the costs of copying, mailing, or other associated supplies. By standards of the American Medical Association, I may deny your request to inspect and/or copy under certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, I will select a licensed health care professional other than myself to review the denial of your request and I will comply with their recommendation. Right to request restrictions. You have the right to request restrictions or limitations to the information I disclose. I am not require to agree to your request. If I do agree, I will comply with your request unless the information is needed to provide you with emergency treatment. Right to an accounting of disclosures. You have a right to request an accounting of disclosures. To obtain a list of such disclosures, you must submit your request to me in writing. It must state a time period which may not exceed seven years prior to the date of the request. The first list you request within a twelve month period will be free of charge. For additional lists, I may charge you the cost of providing the list. To amend. If you believe health information I have about you is incorrect, incomplete, or outdated, you may ask me to amend the information. Such a request should be in writing and should include the information to be amended. I will be unable to directly modify information contained in documents and records which were not created in this office. For instance, if I receive a document from your family doctor which contains information which you believe to be incorrect, I may make note of the correction, but will not directly alter the document sent to me by your doctor. Right to a paper copy or this notice. You have a right to a paper copy of this notice. Even if you have agreed to receive it electronically, you may ask for a paper copy at any time. CHANGES TO THIS NOTICE I reserve the right to change this notice and to make the revised or changed notice effective for clinical information I already have about you as well as any information I receive in the future. I will post a summary of any changes in the office with its effective date. You are entitled to a full copy of the latest notice concerning the privacy policy governing my practice. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with my office and I will try my best to address your concerns formally or informally. You may also file a complaint with the State Board of Psychologist Examiners. Finally, you may file a complaint with the secretary of the Department of Health and Human Services or seek private legal consultation.  You will not be penalized for making a complaint.