Notice of Privacy Practices

This Notice describes how psychological and medical information you share may be used/disclosed, and how you can get access to your counseling/health information.  Therefore, I request that you read the following information, ask any questions you may have, and then sign this form.  Your signature acknowledges that you have reviewed and understand the information provided in this disclosure statement/notice of privacy practices which is required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), effective April 14, 2003.

It is important that counselors take steps to protect the privacy of your “protected health information” (PHI).  PHI refers to information in your health record that could identify you such as your name, student number/social security number, address, and phone number.  Besides PHI, other important terms and definitions are: 

·         Treatment and Health Care Operations

- Treatment is when professional staff provide, coordinate, or manage your health care and other services related to your health care.  An example of treatment would be when your therapist consults with another healthcare provider, such as your family physician, psychologist, or another therapist.  This helps with coordinating your mental healthcare treatment.

-  Health Care Operations are activities that relate to the performance and operation of my counseling practice.  Examples of healthcare operations are quality assessment and improvement activities, administrative services, and care coordination.

·         “Use” applies only to activities within a psychotherapy session such as sharing, applying, utilizing, examining, and analyzing information that identifies you.

·         “Disclosure” applies to activities outside of psychotherapy sessions such as releasing, transferring, or providing access to information about you to other qualified parties, at your request when appropriate.

Client Rights

 I am required by both federal and state law, with certain exceptions, to maintain the confidentiality of the information you share.  I adhere to standards that have been developed in order to maintain the privacy of your counseling/health information, and seek to guarantee the following rights of all recipients of my psychotherapy services:

1.       Right to Appropriate Care.  You have the right to be treated with dignity and respect, the right to receive care that is non-discriminatory, and the right to receive care from qualified professionals.

2.       Right to Referral.  Should you want to receive counseling services from a different therapist, you have the right to request a referral to another place or another counseling professional.  In each case, you will be provided with at least two other places or names.

3.       Right to Terminate Treatment.  You have the right to terminate treatment at any time.  Please remember, appropriate closure may take some time.

4.       Right to Request Restrictions.  You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, I am not required to agree to a restriction request.

5.       Right to Release.  You have the right to consent to/authorize the release of confidential information about you.  I will obtain your written authorization for uses and disclosures that are not identified by this notice/disclosure or required by applicable law. 

6.       Right to Rescind. You may, in writing, withdraw your consent to release confidential information at any time.  However, if disclosures have already been made based on your earlier consent, these disclosures cannot be recovered or undone.

7.       Right to Receive Confidential Communications by Alternative Means and at Alternative Locations.  For instance, you may ask that I contact you at your work/home address/phone, or other location.  I will accommodate reasonable requests.  (NOTE: Email is NOT a confidential means of communication.)

8.       Right to Inspect and Obtain a Copy.  You must submit your request in writing on the appropriate form(s) in order to receive records.  This, however, does not necessarily include psychotherapy notes; and does not include information gathered in anticipation of, or for use, in a civil/criminal, or administrative action; information that I cannot legally disclose to you; or information that we determine should not be disclosed to you because it might hurt you or someone else.

9.       Right to Amend.  If you believe your PHI is incorrect or incomplete, provided the information was created by our office, you may request an amendment to your PHI by contacting Melissa Bennett-Heinz at (509) 242-7274 or in writing.

10.   Right to a Copy of this Notice.  You will be given a copy of this Notice of Disclosure/Privacy Practices.


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

1.       Consultation with Other Professionals: I may consult with other healthcare professionals regarding your status during a staff case conference or in an individual consultation with a supervisor.

2.       Serious Threat to Health or Safety: I may disclose your confidential mental health information to any person without consent/authorization if I have a reasonable belief that disclosure will avoid or minimize an imminent danger to your health or safety or the health or safety of any other individual.

3.       Child Abuse: If I have reasonable cause to believe that a child (anyone under the age of 18-years-of age) has suffered abuse or neglect, I am required by law to report it to the proper law enforcement agency or the Washington Department of Social and Health Services/Child Protection agency 

4.       Adult and Domestic Abuse: If I have reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, I must immediately report the abuse to the Washington Department of Social and Health Services/Adult Protective Services.  If I have reason to suspect that sexual or physical assault of a vulnerable adult has occurred, I must immediately report to the appropriate law enforcement agency and to the Department of Social and Health Services.

5.       Health Oversight: If the Washington State or North Carolina Department of Health subpoenas me as part of its investigations, hearings or proceedings relating to the discipline, issuance, or denial of licensure of state-licensed psychologists, I must comply with its orders.  This could include disclosing your mental health information.

6.       Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that I have provided to you and the records thereof, such information is privileged under state law and I will not release information without the written authorization of you or your legal representative, or a subpoena of which you have been properly notified and you have failed to inform your counselor that you are opposing the subpoena or court order.  The privilege does not apply when you are being evaluated by a third party or where the evaluation is court-ordered (including referrals compelled by the University Student Conduct System).  You will be informed in advance if this is the case.

7.       In addition, the following circumstances may require the use or disclose your psychotherapy/health information without your written permission:

a. To federal officials for intelligence and national security activities authorized by law.

b. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.

c. If you are a member of U.S or foreign military forces (including veterans) and if required by the appropriate authorities.

I, Melissa Bennett-Heinz, value the privacy of your health care information.  I have provided a copy of my Notice of Privacy Practices to you so you may understand how I use and discloses your health information.  I will use your health care information to provide treatment to you, to ensure payment for the services I provide to you and to monitor the quality of my operations.

I, Melissa Bennett-Heinz, reserve the right to change the terms of her Notice of Privacy Practices.  I also reserve the right to make the revised or changed Notice of Privacy Practices effective for all health information I already have about you as well as any health information I receive in the future.