Disclosure Statement

HIPPA / Privacy Practices

Eileen Stein, MSSW, LICSW

1818 Westlake Avenue North, Suite 124, Seattle, WA 98109, 206 937-3972

NOTICE OF HIPPA PRIVACY PRACTICES

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

Please Review this Information CAREFULLY .

I am required by applicable federal and state law to maintain the privacy of your health information. I am also required to give you this Notice of HIPPA Privacy Practices which describes in detail my privacy practices, legal obligations, and your rights concerning your health information ( "Protected Health Information" or "PHI" ). I must follow the privacy practices that are described in this Notice (which may be amended from time to time).For more information about my privacy practices, or for additional copies of this Notice, please contact me using the information listed in Section II G of this notice.

I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

A. Permissible Uses and Disclosures Without Your Written Authorization

I may use and disclose PHI without your written authorization, excluding Psychotherapy Notes as described in Section II, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.

1. Treatment: I may use and disclose PHI in order to provide treatment to you. For example, I may use PHI to diagnose and provide counseling service to you. In addition, I may disclose PHI to other health care providers involved in your treatment for consultaion, coordination, and continuity of care.

2. Payment: I may use or disclose PHI so that services you receive are appropriately billed to, and payment is collected from, your health plan. By way of example, I may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.

3. Health Care Operations: I may use and disclose PHI in connection with our health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities.

4. Required or Permitted by Law: I may use or disclose PHI when I am required or permitted to do so by law. For' example, I may disclose PHI to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. In addition, I may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access PHI ; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions or otherwise as authorized by law

B. Uses and Disclosures Requiring Your Written Authorization

1. Psychotherapy Notes: Notes recorded by me, your clinician, documenting the contents of a counseling session with you ("Psychotherapy Notes") will be used only by me, your clinician, and will not otherwise be used or disclosed without your written authorization.

2. Marketing Communications: I will not use your health information for marketing communications without your written authorization.

NOTICE OF HIPPA PRIVACY PRACTICES CONTINUED:

3. Other Uses and Disclosures: Uses and disclosures other than those described in Section LA. above will only be made with your written authorization. For example, you will need to sign an authorization form before I can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time .

II. YOUR INDIVIDUAL RIGHTS

A. Right to Inspect and Copy Medical/Counseling Records: . You may request access to your medical record and billing records maintained by me in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, I may deny access to your records. I may charge a fee for the costs of copying and sending you any records requested. Note that if you are a parent or legal guardian of a minor, please note that certain portions of the minor's medical record will not be accessible to you.

B. Right to Alternative Communications: . You may request, and I will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.

C. Right to Request Restrictions: You have the right to request a restriction on PHI used for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to the Privacy Officer as indicated below. I am not required to agree to any such restriction you may request.

D. Right to Accounting of Disclosures: . Upon written request, you may obtain an accounting of certain disclosures of PHI made by me after October 1, 2003 This right applies to disclosures for purposes other than treatment, payment or health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations.

E. Right to Request Amendment: You have the right to request that I amend your health information. Your request must be in writing, and it must explain why the information should be amended. I may deny your request under certain circumstances.

F. Right to Obtain Notice: . You have the right to obtain a paper copy of this Notice by submitting a request to the Privacy Officer at any time.

G. Questions and Complaints:. If you desire further information about your privacy rights, or are concerned that I have violated your privacy rights, you may contact the Privacy Officer, Eileen Stein, MSSW, LICSW 206.937.3972

8137. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. I will not retaliate against you if you file a complaint with the Director or myself.

III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE

A. Effective Date: This Notice is effective on October 12, 2003.

B. Changes to this Notice : I may change the terms of this Notice at any time. If I change this Notice, I may make the new notice terms effective for all PHI that I maintain, including any information created or received prior to issuing the new notice. If I change this Notice, I will post the revised notice in the waiting area of my office. You may also obtain any revised notice by contacting the Privacy Officer.

Please Complete/Sign Below:

Eileen Stein, MSSW, LICSW

1818 Westlake Avenue North, Suite 124, Seattle, WA 98109, 206 937-3972

NOTICE OF HIPPA PRIVACY PRACTICES

I, _____________________________, have received a copy of Notice of HIPPA Privacy Practices with respect to my therapy services from Eileen Stein, MSSW, LICSW. This document/signature acknowledges receipt of the Notice in its entirety. I understand that if I have any questions with respect to this Notice, or with respect to Privacy Practices as detailed in the Notice, I will contact the Privacy Officer, Eileen Stein, MSSW, LICSW.

____________________________________/_______________

Client Date

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Therapist Date

Eileen Stein, MSSW, LICSW : 1818 Westlake Avenue North, Suite 124, Seattle, WA 98109, 206 937-3972