Lizzie Crawford, MA., LMHC

581 Boylston Street, Suite 802C, Boston, MA 02116

617 800 9860 lc@lizziecrawford.com

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you

that may identify you and that relates to your past, present or future physical or mental health or condition

and related health care services is referred to as Protected Health Information (“PHI”). This Notice of

Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law,

including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated

under HIPAA including the HIPAA Privacy and Security Rules, the AMHCA and ACA Code of Ethics

and Massachusetts statutes and regulations. It also describes your rights regarding how you may gain

access to and control your PHI.

I am required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and

privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy

Practices. I reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new

Notice of Privacy Practices will be effective for all PHI that we maintain at that time. I will provide you

with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to

you in the mail upon request or providing one to you at your next appointment.

I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS, REQUIRING CONSENT

I may use or disclose your PHI for treatment, payment and health care operations purposes with your

consent as discussed below:

For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the

purpose of providing, coordinating, or managing your health care treatment and related services. This

includes consultation with clinical supervisors or other treatment team members. An example of treatment

would be when I consult with another health care provider, such as a family physician or another mental

health provider. I may disclose PHI to any other consultant only with your authorization.

For Payment. I may use and disclose PHI so that I can receive payment for the treatment services

provided to you. This will only be done with your consent. Examples of payment-related activities are:

making a determination of eligibility or coverage for insurance benefits, processing claims with your

insurance company, reviewing services provided to you to determine medical necessity, or undertaking

utilization review activities. If it becomes necessary to use collection processes due to lack of payment for

services, I will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. I may use or disclose, as needed, your PHI in order to support our business

activities including, but not limited to, quality assessment activities, employee review activities, licensing,

and conducting or arranging for other business activities. For example, I may share your PHI with third

parties that perform various business activities (e.g., billing or typing services) provided we have a written

contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching

purposes PHI will be disclosed only with your authorization.

II. USES AND DISCLOSURES REQUIRING AUTHORIZATION

Uses and disclosures not specifically permitted by applicable law will be made only with your written

authorization, which may be revoked at any time, except to the extent that we have already made a use or

disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization:

• most uses and disclosures of psychotherapy notes which are separated from the rest of your medical

record;

• most uses and disclosures of PHI for marketing purposes, including subsidized treatment

communications;

• disclosures that constitute a sale of PHI;

• other uses and disclosures not described in this Notice of Privacy Practices.

III. USES AND DISCLOSURES WITH NEITHER CONSENT NOR AUTHORIZATION

I may use or disclose PHI without your consent or authorization in the following circumstances:

• 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.

• 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.

• Abused 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.

• Health Oversight: The Board of Registration of Allied Mental Health and Human Service

Professions has the power, when necessary, to subpoena relevant records should I be the focus of

an inquiry.

• 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 we 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.

• 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 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.

• Worker’s Compensation: If you file a workers’ compensation claim, your records relevant to

that claim will not be confidential to entities such as your employer, the insurer and the Division

of Worker’s Compensation.

• Specialized Government Functions. We 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.

• Public Health. If required, we may use or disclose your PHI for mandatory public health

activities to a public health authority authorized by law to collect or receive such information for

the purpose of preventing or controlling disease, injury, or disability, or if directed by a public

health authority, to a government agency that is collaborating with that public health authority.

IV. PATIENTS’ RIGHTS

You have the following rights regarding PHI we maintain about you:

• Right of Access to Inspect and Copy. You have the right to inspect or obtain a copy (or both) of

PHI and psychotherapy notes in my mental health and billing records used to make decisions

about you for as long as the PHI is maintained in the record. Your access may be denied in certain

circumstances, but in some cases, you may be able to have this decision reviewed. On your

request, I will discuss with you the details of the request and denial process. I may charge a

reasonable, cost-based fee for copies. If your records are maintained electronically, you may also

request an electronic copy of your PHI. You may also request that a copy of your PHI be provided

to another person.

• Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may

ask me to amend the information although I am not required to agree to the amendment. If I deny

your request for amendment, you have the right to file a statement of disagreement with me. I

may prepare a rebuttal to your statement and will provide you with a copy. On your request, I will

provide you with details of the amendment process.

• Right to an Accounting of Disclosures. You have the right to request an accounting of PHI for

which you have neither provided authorization nor consent. On request, I will discuss with you

the details of the accounting process. I may charge you a reasonable fee if you request more than

one accounting in any 12-month period.

• Right to Request Restrictions. You have the right to request a restriction or limitation on the use

or disclosure of your PHI for treatment, payment, or health care operations. We are not required

to agree to your request unless the request is to restrict disclosure of PHI to a health plan for

purposes of carrying out payment or health care operations, and the PHI pertains to a health care

item or service that you paid for out of pocket. In that case, we are required to honor your request

for a restriction.

V. YOUR RIGHTS AND OUR OBLIGATIONS

• Right to Receive Confidential Communications by Alternative Means and at Alternative

Locations. You have the right to request that we communicate with you about health matters in a

certain way or at a certain location. I will accommodate reasonable requests. (For instance, you

may not want a family member to know you are seeing us. Upon your request, we will send your

bills to another address.) I may require information regarding how payment will be handled or

specification of an alternative address or other method of contact as a condition for

accommodating your request. I will not ask you for an explanation of why you are making the

request.

• Breach Notification. If there is a breach of unsecured PHI concerning you, I may be required to

notify you of this breach, including what happened and what you can do to protect yourself.

• Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice upon

request, even if you have agreed to receive the notice electronically.

OUR OBLIGATIONS

I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties

and privacy practices with respect to PHI. I reserve the right to change the privacy practices described in

this Notice. Unless I notify you of such changes, however, I am required to comply with the terms

currently in effect.

COMPLAINTS

If you have any questions or complaints, you may contact me directly by phone or in writing. You may

also send a written complaint to the Secretary of Health and Human Services at 200 Independence

Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619- 0257. I will not retaliate against you for

filing a complaint.

This notice will go into effect on _____________________ .