IN ACCORDANCE WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA), THIS NOTICE OF PRIVACY PRACTICES (“NOTICE”) DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AS WELL AS HOW YOU MAY GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY AND SIGN THE ACKNOWLEDGEMENT OF RECEIPT.

This Notice will explain how we handle your medical/mental health information. Applicable federal and state laws require us to maintain the privacy of clients’ personal and health information. In this Notice, your personal or protected health information is referred to as “health information” or “PHI” and includes information regarding your health care and treatment with identifiable factors, such as your name, age, address, income or other financial information. In addition, Wolff Child Psychology is required by law to provide Individuals with notice of its legal duties and privacy practices with respect to PHI. That is the purpose of this Notice. Because state and federal laws, combined with our professional ethics, are very complicated, some parts of this Notice are very detailed and may seem difficult to understand. Please know that Wolff Child Psychology, PLLC (“Wolff Child Psychology”) is committed to protecting the privacy of your health and personal information.

Wolff Child Psychology may use or disclose your health information for treatment, payment, and health care operations purposes if you have given consent to receive evaluation or treatment services. Such use and disclosure does not require additional written authorization.

Definition of Use: Activities within the office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

Definition of Disclosure: Activities outside of the office, such as releasing, transferring, or providing access to information about you to other parties.

Treatment: We may use medical information about you to provide, coordinate, or manage your health care and related services. For example, we may disclose medical information about you to doctors, nurses, hospitals, and other health facilities that become involved in your care as well as those that may assist with your care after you leave our office, such as home health agencies or another health care provider.

Payment: We may use and disclose medical information about so we can be paid for the services we provide to you. This can include billing you or providing information to your insurance company or someone else who is involved in paying for your care. For example, we may need to give your insurance company information about care you had so the company will reimburse you for our services.

Health Care Operations: We may use and disclose medical information about you for our own health care operations. For example, we may use medical information to review your treatment and our services and to evaluate our performance in caring for you, and we use external security cameras for the safety of our employees and patients.

Wolff Child Psychology may use or disclose PHI without your additional written authorization in the following situations:

Contacting You: Unless you tell us otherwise in writing, we may contact you by telephone, e mail, or mail at either your home or your office. We may leave messages for you on your answering machine or voicemail, or with someone who answers the phone. We will try not to leave messages with specific information about you. If you want us to communicate with you in a certain way or at a certain location, let us know so that you may be given a form to make this request.

Appointment Reminders: We may use and disclose medical information about you to remind you of an appointment you have with us. Reminders may be sent through the mail, done over the phone or e-mailed.

Disaster Relief: We may use and disclose medical information about you to a public or private organization authorized by law or by its charter to assist in disaster relief efforts. This will be done to coordinate notifying family members, other relatives, close personal friends, or other people identified by you of your location, general condition, or death.

When Required by Law: We may use and disclose medical information about you when we are required to do so by federal, state, or local law.

Public Health Activities: We may disclose medical information about you for public health activities and purposes. This includes reporting medical information to a public health authority that is authorized by law to collect or receive the information for purposes or preventing or controlling a disease. These activities generally include, but are not limited to, the following: To prevent or control disease, injury or disability; to report child abuse and neglect; to report reactions to medications or problems with products; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. Victims of Abuse, Neglect, or Domestic Violence: We may disclose medical information about you to a government agency authorized by law to receive reports of abuse, neglect, or domestic violence, if we believe you are a victim of abuse, neglect, or domestic violence. This will occur to the extent the disclosure is: (a) required by law; (b) agreed to by you; or (c) authorized by law and we believe the disclosure is necessary to prevent serious harm to you or to other potential victims. If you are incapacitated and certain other conditions are met, information may be given to a law enforcement officer or other public official if he or she indicates that immediate enforcement activity depends on the disclosure. Health Oversight Activities: We may disclose medical information about you to a health oversight agency for activities authorized by law. These activities are necessary for the government to monitor the health care system, government programs, our compliance with civil rights laws, and to make sure we are complying with various government regulations. For example, the Department of Health and Human Services may come in and review records to make sure we are providing quality care to our clients.

Judicial and Administrative Proceedings, Lawsuits and Disputes: We may disclose medical information about you in the course of any judicial or administrative proceeding in response to an order of the court or administrative tribunal. We also may disclose medical information about you in response to a subpoena, discovery request, or other legal process, but only if efforts have been made to tell you about the request or to obtain an order protecting the information from being disclosed.

Law Enforcement: We may disclose medical information about you if required to do so by a law enforcement official. Such requests generally include, but are not limited to, the following: in response to a court, grand jury, or administrative order, a subpoena, warrant, a summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about an actual or suspected victim of a crime and that person agrees to the disclosure (if we are unable to obtain that person’s agreement, in limited circumstances, the information may still be disclosed); about a death we believe may be the result of criminal conduct; about criminal conduct on the grounds of our office building; in emergency circumstances to report a crime, the location of a crime or victims, or the identity, description, or location of the person who committed the crime; or as required by law.

Coroners, Medical Examiners, and Funeral Directors: We may disclose medical information about you to a coroner, funeral director, or medical examiner as necessary for them to carry out their duties.

Organ, Eye, or Tissue Donation: If you are an organ donor, we may disclose medical information about you to organizations or organ banks that handle organ procurement or organ, eye, or tissue transplantation, as necessary to promote organ or tissue donation and transplantation.

To Prevent a Serious Threat to Health or Safety: We may use or disclose medical information about you if we believe the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public. Any disclosure would only be to someone able to help prevent the threat. We also may disclose information about you if we believe the disclosure is necessary for law enforcement authorities to identify or apprehend an individual who admitted participation in a violence crime or who is an escapee from a correctional institution or from lawful custody.

Military and Veterans: If you are a member of the Armed Forces, we may use and disclose medical information about you for activities deemed necessary by the appropriate military command authorities to assure the proper execution of the military mission. We may also release information about foreign military personnel to the appropriate foreign military authority for the same purposes.

National Security and Intelligence: We may disclose medical information about you to authorized federal officials for the conduct of intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates and Persons in Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official having custody of you. This release will be made if it is necessary (l) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Workers Compensation: We may disclose medical information about you to the extent necessary to comply with workers' compensation and similar laws that provide benefits for work related injuries or illness.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, medications or injections, to enable product recalls, repairs or replacement.

Business Associates: Some of the functions of Wolff Child Psychology may be provided by contracts with Business Associates. For example, some of the billing, legal, auditing, and practice management services may be provided by contracting with outside entities to perform those services. In those situations, PHI will be provided to those contractors as is needed to perform their contracted tasks. Business Associates are required to enter into an agreement maintaining the privacy of the PHI released to them.

Other Uses and Disclosures: Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time by writing. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written permission. We are unable to take back any disclosures we have already made with your permission.

Wolff Child Psychology may use or disclose PHI for additional purposes when your authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when the office is asked for information for purposes outside of Treatment, Payment, or Health Care Operations, we will obtain an authorization from you before releasing this information. Specific authorization is also obtained before releasing your psychotherapy notes. Psychotherapy notes are notes made about treatment and are given a greater degree of protection than PHI. You may revoke all such authorizations at any time, provided each revocation is in writing. After that time, we will not use or disclose your information for the purposes originally agreed upon. However, we cannot take back any information already disclosed with your permission or that we had used in our office.

Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request that we restrict the uses or disclosures we make to: (a) a family member, other relative, a close personal friend or any other person identified by you; or, (b) to public or private entities for disaster relief efforts. You also have the right to limit 

the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. Unless you pay for your services out of pocket, we are not required to agree to your request. If you pay for a service out of pocket, you are permitted to demand that information regarding the service not be disclosed to your health plan or insurance. If we do agree with your restriction request, we will comply with your request unless the information is needed to provide you emergency treatment. Even if we agree to a restriction, either you or we can later terminate the restriction. To request restrictions at Wolff Child Psychology you must make your request in writing to Dr. Brian Wolff. In your request, you must tell us (l) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. We will notify you in writing of the outcome of your request within sixty (60) calendar days.

Right to Receive Confidential Communications: You have the right to request that we communicate medical information about you to you in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. We will not require you to tell us why you are asking for the confidential communication. If you want to request confidential communication, you must do so in writing. Your request must state how or where you can be contacted. You will be notified if your request can be granted. We will attempt to accommodate all reasonable requests. However, we may, when appropriate, require information from you concerning how payment will be handled.

Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect or copy medical information about you, you must submit your request in writing to Dr. Brian Wolff. Your request should state specifically what medical information you want to inspect or copy. We will act on your request within thirty (30) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying. We may deny your request to inspect and copy medical information if the medical information involved is: psychotherapy notes; information compiled in anticipation of or use in, a civil, criminal or administrative action or proceeding; or information that is not part of the record set we use to make decisions about your care and treatment. If we deny your request, we will inform you of the basis for the denial, how you may have our denial reviewed, and how you may complain. If you request a review of our denial, it will be conducted by a licensed health care professional designated by us who was not directly involved in the denial. We will comply with the outcome of that review.

Right to Request Amendments: You have the right to ask us to amend medical information about you if you feel the information we have about you is incorrect or incomplete. You have this right for so long as the medical information is maintained by us. To request an amendment of a record, you must submit your request in writing to Dr. Brian Wolff. Your request must state the amendment desired and provide a reason in support of that amendment. We will act on your request within sixty (60) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request. If we grant the request, in whole or in part, we will need you to identify others we need to notify about the change. We also will make the appropriate amendment to the medical information by appending or otherwise providing a link to the amendment. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the medical information kept by us; is not part of the information which you would be permitted to inspect or copy; or is felt to be accurate and complete as originally documented by the person who recorded the information. If we deny your request, we will inform you of the basis for the denial. You will have the right to submit a statement disagreeing with our denial. We may prepare a response to that statement. Your request for amendment, our denial of the request, your statement of disagreement, if any, and our rebuttal, if any, may then be appended to the medical information involved or otherwise linked to it. Dr. Brian Wolff should be notified of your request to have any of this information added to your medical record. Information that is added will then be included with any subsequent disclosure of the information, or, at our election, we may include a summary of any of that information.

Right to an Accounting of Disclosures: You have the right to receive an accounting of disclosures of medical information about you. The accounting may be for up to six (6) years prior to the date on which you request the accounting. Your request must state a time period for the disclosures. Under certain circumstances your right to an accounting of disclosures may be suspended for disclosures to a health oversight agency or law enforcement official. Certain types of disclosures will not be included in the accounting: disclosures to carry out treatment, payment, and health care operations; disclosures of your medical information made to you; disclosures for national security or intelligence purposes; disclosures to correctional institutions or law enforcement officials; and Disclosures that you have authorized in writing. To request an accounting of disclosures, you must submit your request in writing to Dr. Brian Wolff. Usually, we will act on your request within sixty (60) calendar days after we receive your request. Within that time, we will either provide the accounting of disclosures to you or give you a written statement of when we will provide the accounting and why the delay is necessary. There is no charge for the accounting we provide to you.

Right to Receive Notification of Breach: In the event of any breach of your unsecured PHI, Wolff Child Psychology will notify you of such breach within sixty (60) days of the date it learns of the breach.

Right to Copy of this Notice: You have the right to obtain a copy of our Notice of Privacy Practices at any time. To obtain a copy of this Notice, contact Dr. Brian Wolff.

Our Right to Change Notice of Privacy Practices: We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. The Notice will contain the effective date on the first page. When the Notice is revised, the revised Notice will be posted on Wolff Child Psychology’s website will be available upon request.

Complaints: You may complain to us and to the United States Secretary of Health and Human Services if you believe we have violated your privacy rights. These complaints must be in writing and must be filed within 180 days of when you learn of or should have known about the violation. To complain to the Secretary of the Department of Health and Human Services contact: Region VIII, Office for Civil Rights, U.S. Department of Health and Human Services, th 999 18 St., Suite 417, Denver, CO 80294. Phone: (800) 368-1019. Fax: (303) 844-2025. To file a complaint with us, contact Dr. Brian Wolff. All complaints should be submitted in writing. You will not be retaliated against or penalized for filing a complaint. We will not take any action against you or change our treatment of you in any way.

Questions and Information: If you have any questions or want more information concerning this Notice of Privacy Practices for Wolff Child Psychology, please contact Dr. Brian Wolff at 3345 th W. 38 Avenue, Denver, CO 80211, or by phone at 303-500-3407.

I have received a copy of the Notice of Privacy Practices from Wolff Child Psychology, containing a complete description of the uses and disclosures of my health information. I have been given the right to review this Notice of Privacy Practices prior to signing this consent. I understand that Wolff Child Psychology has the right to change this Notice of Privacy Practices (for example, if there is a change in the law I may contact Wolff Child Psychology,at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that Wolff Child Psychology, restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand Wolff Child Psychology, is not required to agree to my requested restrictions, with the one exception identified in the Notice of Privacy Practices. I understand that I may revoke this consent in writing at any time, except to the extent that Wolff Child Psychology, has taken action relying on this consent.