This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.


When it comes to our health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

  • The right to inspect and receive a paper or electronic copy of PHI (Protected Health Information), as applicable. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable fee.
  • The right to amend PHI, as applicable. You can ask us to correct health information about you that you think is incorrect or incomplete. We may say “no” to your request, but we will notify you within 60 days.
  • The right to receive confidential communications of PHI, as applicable. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
  • The right to request restrictions on certain uses and disclosures of PHI. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • The right to restrict certain disclosures of PHI to a health plan. If you pay for a service of health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment for our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
  • The right to receive an accounting of disclosure of PHI, as applicable. You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but additional requests within the same period, we may charge you for reasonable costs of providing this accounting.
  • The right to obtain a paper copy of this Notice from LMHC upon request. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
  • The right to file a complaint if you feel your privacy rights are violated. If you feel your rights have been violated in receiving services at LMHC you should first discuss your concerns with your therapist.  If you feel that your concerns are yet unresolved, you can then speak to the Program Supervisor.  If you continue to feel your concerns have not been addressed, the grievance process continues to the respective Site Director, Privacy Officer, the Executive Director and the Board of Directors.

While we are confident that this process will adequately address your concerns, you also have the option of contacting professional boards, or you may also contact:

Minnesota Department of Human Services
Mental Health Division
P.O. Box 64981
St. Paul, MN 55164-0981
Phone:  651-431-2225
Fax:  651-431-7418

U.S. Department of Health and Human Services for Office of Civil Rights
200 Independence Ave SW
Washington, DC 20201
Phone:  877-696-6775

We support your right to the privacy of your health information.  We will not retaliate in any way if you choose to file a complaint.

Our Uses and Disclosures

All personal information about you, or the services provided to you, is confidential unless you, or your legally authorized representative, give us written permission for release of your records. We are allowed to share your information in the following ways:

  • For treatment – We can use your health information and share it with other professionals who are treating you. (example, multidisciplinary team case consultation)
  • For payment – We can use and share your health information to bill and get payment from health plans or other entities. (examples – determining insurance eligibility or coverage, obtaining prior authorization from an insurance company for a service, or billing an insurance for a service provided).
  • For health care operations – We can use and share your health information to run our practice, improve your care, and contact you when necessary (example – outcomes evaluation or quality assessment activities)

Certain State and Federal laws mandate us to share your PHI information:

  • Admission of child or vulnerable adult abuse, which therapists are required by law to report even if the information was received in confidence.
  • Threats of suicide and/or self-harm, or threats of bodily harm to another person.
  • For law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law, for special government functions such as military, national security, and presidential protective services.
  • Response to lawsuits and legal actions – we can share health information about you in response to a court or administrative order, or in response to a subpoena.
  • We do not share your PHI information for fundraising activities, marketing purposes, or research.
Our Responsibilities
  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy and security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
Changes to the Terms of This Notice of Privacy Practice

We can change the terms of this notice and the changes will apply to all information we have about you. The new notice will be available, upon request, in our office and on our web site.

Effective Date Of Notice:  09/23/13