Individual Private Practice Clinicians practicing out of the Office Suite:
10109 N. Division St., Suite 109, Spokane, Washington 99218
James Pattee, MA, LMHC, LMFT Tory Daniewicz, MS, LMHC
Lisa Koch, Ph.D. Curtis Mulder, MA, LMHC
Tiffanie O’Rourke, MA, LMHC Patricia Sittser, RN, MA, LMHC
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.
I am required by applicable federal and state laws to maintain the privacy of your protected health information (PHI). I am also required to give you this Notice about privacy practices, my legal duties, and rights concerning your protected health care information. I will abide by the terms of this Notice while it is in effect. The privacy practices described in this Notice takes effect November 25, 2014.
I reserve the right to change the privacy practices and the terms of this Notice and to make the revised Notice effective for all information I maintain including information received prior to the revisions. Revised Notices will be posted in my office. You may request a copy of this Notice, or any subsequent revised Notice at any time.
I will also inform you following an unsecured breach of your PHI.
Uses and Disclosures of Protected Health Information with Your Consent
After you have read this Notice, you will be asked to sign a separate Consent Form to allow me to use and disclose your protected health information. In most all cases, your protected health information will be used and disclosed for the purposes of providing treatment to you, arranging for payment for my services and certain administrative functions called healthcare operations.
Treatment: I will use and disclose your protected health information to provide, coordinate, or manage your treatment. This includes the coordination of your healthcare with others who provide treatment to you. For example, I may share your information to a physician or another therapist who may be treating you or to whom you have been referred in order to coordinate your care and determine the best course of treatment.
Payment: I will use and disclose your protected health information, as needed, to obtain payment for treatment provided to you. For example, your health care plan may request specific information such as your diagnoses, treatment procedures and progress before it approves or pays for the services I recommend for you.
Healthcare operations: I may use and disclose, as needed, your protected health information in order to conduct certain business and operational activities. For example, I may share your protected health information with third-party, “business associates”, that perform various activities, such as billing services, for the practice. All business associates will be bound by a written contract to protect the privacy of your information.
I may also use or disclose your information, as necessary, to contact you for rescheduling or confirming appointments. Please let us know if you would like us to contact you in a certain way or in a certain location, such as calling you only at home or work.
Uses and Disclosures Requiring Your Authorization
Other uses and disclosures of your protected health information for purposes other than for treatment, payment, healthcare operations or the exceptions described below in this notice, will be made only with your written authorization.
If you do authorize us to use or disclose your protected health information, you can revoke that permission, in writing, at any time. Revocation will stop future uses or disclosures of your information for the purposes originally authorized. Without your authorization, we will not disclose your information except as described in this Notice.
Uses and Disclosures Not Requiring Your Consent or Authorization
When Required by Law: There are some federal or state laws which require us to disclose protected health information:
- We must disclose information to the appropriate authorities if there is any reason to believe that a child, developmentally disabled adults, or adult dependent is being abused or neglected.
- We must disclose information if there is any reason to believe that there is a serious threat to your health or safety or that of another person(s).
- We may have to disclose specific information if you are involved in a lawsuit or legal proceeding and we received a court order or subpoena.
- We may disclose information to law enforcement authorities, if necessary, to assist in apprehending criminal offenders.
- We may disclose information about you for Workers Compensation or similar programs.
- We must disclose your protected health information to the U.S. Department of Health and Human Services upon request for purposes of determining whether we are in compliance with federal privacy laws.
Restriction requests: You have the right to request restrictions on the use and disclosure of your protected health information for treatment, payment, healthcare operations and to those involved in your care except when specifically authorized by you, required by law, or in emergency situations. Your request must be in writing. We will consider your request, however, we are not legally required to accept it.
Confidential communication: You have the right to request that your information be communicated to you in a confidential manner, such as sending mail to an address other than your home. The request must be in writing and specified how or where you wish to be contacted.
Access: You have the right to inspect or copy your protected health information, with limited exceptions. Your request to inspect or copy your information must be in writing. A fee will be charged to cover the cost of copying, mailing or other activities associated with your request.
Amendment: You have the right to request that we amend your protected health information if you believe that the information is incorrect or incomplete. Your request must be in writing and describe the reasons for your request. We may deny your request if the information in question was not created by us, is not part of the information that you would be permitted to review or copy, or is accurate and complete.
Accounting of disclosures: You have the right to receive a list of instances in which we or our business associates disclose your protected health information for purposes other than treatment, payment, healthcare operations and other functions described above. Your request must be in writing. Accounting disclosures will include disclosures made for the past six years, but not include dates prior to April 14, 2003.
Right to Pay Out of Pocket: You have the right to pay out-of-pocket for a service and the right to require that I not submit your PHI to your health plan if you pay out-of-pocket.
Paper Copy of This Notice: You are entitled to a paper copy of this Notice even if you have received this Notice electronically.
Electronic PHI: If you request an electronic copy of your PHI, then I must provide access to that information in electronic form, if it is readily producible in that form. I will have to produce your PHI in an electronic format if I maintain records electronically. If you direct me, in a signed writing, to electronically transmit a copy of your PHI to another person designated by you, then I must transmit the PHI electronically to that party.
Psychotherapy Notes: Most uses and disclosures of psychotherapy notes (where appropriate), uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI require your authorization.
Other Uses and Disclosures: Other uses and disclosures not described in this Notice of Privacy Practices will be made only with your written authorization.
Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us using the information below. If you believe that we may have violated your privacy rights, or you disagree with the decision we made about access to your protected health information or other request, you may complain to us using the contact information below. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We will support your right to protect the privacy of your protected health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Each individual clinician is an independent practitioner and should be contacted individually as to your concerns regarding this Privacy Practices Notice and your PHI.
For Independent Counseling Service staff (reception/billing services) and James Pattee, MA, LMHC, LMFT, please contact James Pattee.
For Lisa Koch, Ph.D., please contact Lisa Koch.
For Tory S. Daniewicz, MS, LMHC, please contact Tory Daniewicz.
For Curtis J. Mulder, MA, LMHC, please contact Curtis Mulder.
For Patricia E. Tozer Sittser, RN, MA, LMHC, please contact Patricia Sittser.
For Tiffanie O’Rourke, MA, LMHC, please contact Tiffanie O’Rourke
Telephone: (509) 467-1156 Fax: (509) 468-0462
10109 N. Division, Suite 109
Whitworth Professional Center
Spokane, Washington 99218