Effective Date: June 14, 2026
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. OUR PLEDGE REGARDING HEALTH INFORMATION:
We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with specific legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you how we may use and disclose your health information. It also describes your rights to the health information we keep about you and the obligations we have regarding the use and disclosure of your health information.
We are required by law to:
• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of our legal duties and privacy practices concerning health information.
• Follow the terms of the notice that is currently in effect.
• We can change the terms of this Notice, which will apply to all information we have about you. The new Notice will be available upon request in our office and on our website.
Breach Notification: We are required by law to maintain the privacy and security of your protected health information. In the event of a breach—meaning your unsecured PHI is compromised through unauthorized access, acquisition, use, or disclosure—we will notify you without unreasonable delay and, in no case, later than 60 days after discovery of the breach.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose health information. For each category, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment Payment or Health Care Operations: Federal privacy rules and regulations allow healthcare providers who have a direct treatment relationship with the client to use or disclose the client’s personal health information without the client’s written authorization to carry out the healthcare provider’s own treatment, payment or health care operations. We may also disclose your protected health information for the treatment activities of any healthcare provider. This, too, can be done without your written authorization. For example, if a clinician were to consult with another licensed healthcare provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, to assist the clinician in diagnosing and treating your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another. Lawsuits and
Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
1. Psychotherapy Notes. We do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For our use in treating you.
b. For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For our use in defending ourselves in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
2. Substance Use Disorder Records:
The confidentiality of substance use disorder patient records maintained by this practice is protected by federal law and regulations (42 CFR Part 2). Generally, we may not say to a person outside the program that you attend the program, or disclose any information identifying you as having a substance use disorder unless:
1. You consent in writing;
2. The disclosure is allowed by a court order; or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.
Violation of federal laws and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.
3. Marketing Purposes. As psychotherapists, we will not use or disclose your PHI for marketing purposes.
4. Sale of PHI. As psychotherapists, we will not sell your PHI in the regular course of our business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:
1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on our premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
9. For workers' compensation purposes. Although we prefer to obtain your Authorization, we may provide your PHI to comply with workers' compensation laws.
10. Appointment reminders and health-related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us. We may also use and disclose your PHI to tell you about treatment alternatives or other healthcare services or benefits that we offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
1. Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person you indicate is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergencies.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record or a summary of it if you agree to receive a summary within 30 days of receiving your written request, and we may charge a reasonable, costbased fee for doing so.
5. The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost-based fee for each additional request.
6. The Right to Correct or Update Your PHI. If you believe your PHI contains a mistake or that critical information is missing, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving it.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
VII. COMPLAINTS AND CONTACT INFORMATION
If you believe your privacy rights have been violated, or if you disagree with a decision we made about access to your records, you may file a complaint with our practice or with the Secretary of the U.S. Department of Health and Human Services.
-To file a complaint with us: Please contact our Privacy Officer directly at 314-516-3718 or by mail at Alpine's Empowerment Agency, 3609 Austin Bluffs Pkwy, Ste 311023 Colorado Springs, CO 80918- 6658.
-To file a complaint with the government: You can send a letter to the U.S. Department of Health and Human Services Office for Civil Rights (OCR) or file a complaint online via the OCR Complaint Portal. We will not retaliate against you in any way for filing a complaint.