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As part of my professional practice, I maintain personal information about you and your physical and mental health. “Protected health information” (“PHI”) is information about you that may identify you and that relates to your past, present or future physical or mental health condition, services provided, or payment for those services. This Notice of Privacy Practices describes your rights regarding that information, how I may use and disclose that information and my duties to protect that information in accordance with applicable law and the Social Work Code of Ethics.

How I May Use And Disclose Health Information About You

For Treatment. Your health information 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. An example of treatment would be when I consult with another health care provider, such as your family physician or another mental health provider involved in your care. In case of emergency, a family member may be contacted. In certain circumstances, I may contact you to discuss treatment options, or to provide follow up to a referral.

For Payment. Your health information may be used in connection with billing statements I send you and for tracking charges and credits to your account. In addition, but with your authorization, I may disclose your health information to third party payers to obtain information concerning benefits, eligibility, and coverage, as well as to submit claims for payment. I may also disclose your health information for medical necessity and utilization review purposes. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of identifying information necessary for purposes of collection.

For Health Care Operations. Your health information may be used or disclosed for the health care operations of my professional practice. Such disclosures would be to provide quality assurance, peer review, administrative, legal, or financial services to assist me in my delivery of your health care.

Other Uses And Disclosures Also Not Requiring Your Authorization

Required by Law. I may use or disclose your health information to the extent that itís use or disclosure is required by law. Examples are public health reports, child or adult abuse reports, law enforcement reports, workerís compensation programs, and reports to coroners, medical examiners in connection with investigation of deaths and if you make a complaint against me to the Washington State Department of Health. I also must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.

Health Oversight. I may disclose your health information to a health oversight agency for activities authorized by law, such as my professional licensure. Oversight agencies also include government agencies and organizations that audit their provision of financial assistance to me (such as third-party payers).

Threat to Health or Safety. I may disclose your health information when necessary to minimize an imminent danger to the health or safety of you or any other individual.

Business Associates. I may disclose your health information to Business Associates that are contracted by me to perform health care operations or payment activities on my behalf. My contract with them must require them to safeguard the privacy of your protected health information.

Court Order. I will disclose your protected health information if I am ordered to do so by a court order or other lawful process.

Uses And Disclosures Requiring Your Written Authorization

I will make other uses and disclosures of your protected health information only with your written authorization. You may revoke this authorization in writing at any time. Of course, I am unable to take back any disclosures I have already made with your permission prior to a revocation.

Your Rights Regarding Your Health Information

You have a right to:

  • Request access to or a copy of your health information. Your request must be made in writing and will be denied only in certain limited situations. I may charge a reasonable fee for producing and mailing the copies.
  • Ask me to amend the health information in your record if you believe it is incorrect or incomplete. Your request must be in writing and must provide the reason for your request. In certain cases, I may deny your request.
  • Seek an accounting of disclosures by asking me in writing for a list of the disclosures I have made of your health information, except for disclosures for treatment, payment and health care operations.
  • Request restrictions by asking that I limit the way I use or disclose your medical information for treatment, payment, or health care operations. I am not required to agree to your request.
  • Request communication with you by another means to preserve confidentiality. For example, if you want me to communicate with you at a different address or telephone number I can usually accommodate your request if it is reasonable.
  • Receive a paper copy of this notice.

Changes to this Notice

This notice, effective July 1, 2004, may be changed at any time. Any new Notice of Privacy Practices will be effective for all health information that I maintain at that time. A current Notice will be posted on my website, www.nancyadlerjones.com.


If you believe your privacy rights have been violated, you may contact me, the Privacy Officer at 425-948-4055, or submit your complaint in writing to Nancy Adler-Jones, MSW, Privacy Officer, 3101 Oakes Ave. Everett, WA 98201. If I cannot resolve your concern, you may also contact the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

To contact Nancy, call 425-948-4055 or email nancy@nancyadlerjones.com