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Dr. Susan Cummings Nicholson, PhD, LCSW, BCD


Notice of 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 it carefully.

We are required by law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, legal obligations, and your rights concerning your health information (“Protected Health Information” or “PHI”). We will follow the privacy practices that are described in this Notice. If this Notice is amended, we will provide you with the amended Notice for your information and signature. For more information about our privacy practices, or for additional copies of this Notice, please let your provider know your questions as soon as they arise.

I. Uses and disclosures of protected health information (PHI)

A. Permissible Uses and Disclosures Without Your Written Authorization. Your provider may use and disclose your PHI without your written authorization 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 disclosure of your mental health information that are legally permissible.

1. Treatment: Your provider may use and disclose your PHI to other clinicians involved in your care in order to better provide integrated treatment to you. For example, your provider may discuss your diagnoses and treatment plan with your psychiatrist, psychotherapist or nurse practitioner. In addition, your provider may disclose your PHI to other health care providers in order to provide you with appropriate care and continued treatment.
2. Payment: Your provider may use or disclose your PHI for the purpose of determining coverage, billing, claims management, and reimbursement. For example, a bill sent to your health insurer may include some information about your treatment plan and progress, so that the insurer will pay for the treatment. Your provider may also inform your health plan(s) about a treatment you are going to receive in order to determine whether the plan will cover the treatment.
3. Health Care Operations: Your provider may use and disclose your PHI in connection with health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities. For example, your provider may disclose disguised information about your work together for training purposes.
4. Required or Permitted by Law: Your provider may use or disclose your PHI when required or permitted to do so by law. For example, your provider may disclose your PHI to appropriate authorities if he/she reasonably believes that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes. In addition, your provider may disclose your 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 your 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, disclosures for workers’ compensation claims, and disclosures to military and national security agencies, coroners, medical examiners, and correctional institutions as authorized by law.

B. Permissible Uses and Disclosures That May Be Made Without Your Authorization, But For Which You Have An Opportunity to Object.

1. Family and Other Persons Involved In Your Care: Your provider may use or disclose your PHI to notify, or assist in the notification of (including identifying or locating) your personal representative, or another person responsible for your care, location, general condition, or matters after your death. If you are present, your provider will provide you with an opportunity to object prior to such uses or disclosures. In the event of your incapacity or emergency circumstances, your provider will disclose your PHI consistent with your prior expressed preference, and in your best interest as determined by professional judgment. Your provider will also use professional judgment and experience to make reasonable inferences of your best interest in allowing another person access to your PHI regarding your treatment with us.
2. Disaster Relief Efforts: Your provider may use or disclose your PHI to a public or private entity authorized by law or its charter to assist in disaster relief efforts for the purpose of coordinating notification of family members of your location, general condition, or death.

C. Uses and Disclosures Requiring Your Written Authorization

1. Psychotherapy Notes: Your provider will not disclose any notes made about conversation during your therapy sessions, which have been kept separate from your medical record, without your written permission, except as permitted by law.
2. Other Uses and Disclosures: Uses and disclosures other than those described in this Notice will only be made with your written authorization. For example, you will need to sign an authorization form before your provider can send your PHI to your life insurance company or to your attorney. You may revoke any such authorization at any time by providing your provider with written notification of such revocation.

II. Your individual rights

A. Right to Inspect and Copy. You may request access to your medical records and billing records maintained by your provider in order to inspect or request copies of the records. All requests for access must be made in writing to your provider. Under limited circumstances, your provider may deny access to your records. Your provider may charge a fee for the costs of copying and sending you any records requested.
B. Right to Alternative Communications. You may request, and your provider will accommodate any reasonable written request for you to receive your PHI by alternative means of communications used at this practice or at alternative locations.
C. Right to Request Restrictions. You have the right to request a restriction on your PHI that your provider uses or discloses for treatment, payment or health care operations. You must request any such restriction in writing addressed to your specific provider at Thimble Shoals Counseling & Therapy Center, 703 Thimble Shoals Boulevard, Suite A3, Newport News, VA 23606. Your provider is not required to agree to any such restriction you may request, except if your request is to restrict disclosing your PHI to a health plan for the purpose of carrying out payment or health care operations, the disclosure is not otherwise by law, and the PHI pertains solely to a health care item or service that has been paid in full by you or another person or entity on your behalf.
D. Right of Accounting of Disclosures. Upon written request, you may obtain an accounting of disclosure of your PHI made by your provider in the last six years, subject to certain restrictions and limitations.
E. Right to Request Amendment. You have the right that your provider amends your PHI. Your request must be in writing, and should explain why the information should be amended. Your provider 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 your specific provider at Thimble Shoals Counseling & Therapy Center, 703 Thimble Shoals Boulevard, Suite A3, Newport News, VA 23606, at any time.
G. Right to Receive Notification of a Breach. Your provider is required to notify you if he/she discovers a breach of your unsecured PHI, according to requirements under federal law.
H. Question and Complaints. If you desire further information about your privacy rights, or are concerned that your provider has violated your privacy rights, please contact your specific provider at Thimble Shoals Counseling & Therapy Center, 703 Thimble Shoals Boulevard, Suite A3, Newport News, VA 23606. You may also file a written complaint with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Your provider will not retaliate against you if you file a complaint.

III. Effective date and changes to this notice

A. Effective Date. This Notice is effective on September 23, 2013.
B. Changes to This Notice. If your provider changes any of the terms in this Notice at any time, he/she may make the new Notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new Notice. If a change occurs, your provider will post the revised Notice in the office waiting area and on our website at You may also obtain a copy of any revised Notice by asking your specific provider at Thimble Shoals Counseling & Therapy Center, 703 Thimble Shoals Boulevard, Suite A3, Newport News, VA 23606, directly.