OF PRIVACY PRACTICES
notice describes the privacy practices followed by
this practice, professionals, staff, and other
office personnel including any practitioner who
might provide "call coverage" for your practitioner.
notice applies to the information and records we
have about your health, health status, and the
services you receive from this practice. We are
required by the Health Insurance Portability and
Accountability Act (HIPAA) to give you this notice.
It will tell you about the ways in which we may use
and disclose health information about you and
describes your rights and our obligations regarding
the use and disclosure of that information. Much of
this disclosure may not apply to e-therapy, but you
should read this document in its entirety so you
understand the issues.
MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
State law and the ethics of our mental health
professions, we must have your written, signed
Consent to use and disclose health information for
the following purposes:
We use health information about you to provide you
with clinical services. We may disclose health
information about you to office staff or other
personnel who are involved in taking care of you and
your health. For example, to a licensed mental
health professional who would provide emergency
coverage during an absence of your practitioner or
for consultations with and between other health care
may contact you to provide information about
treatment alternatives or other heath-related
benefits and services that may be of interest to
notify us if you do not wish to be contacted for
appointment reminders or information about treatment
alternatives or other heath-related benefits and
services, or if there are restrictions you want to
make about such contact.
may revoke your Consent at any time by giving us
written notice. Your revocation will be effective
when we receive it, but it will not apply to any
uses and disclosures that occurred before that time.
If you are receiving Substance Abuse Treatment,
Federal and State law require your written
Authorization each time we release health
information. The Authorization will specify who is
to receive the information, the purpose of the
release of information, and a time period after
which the Authorization will terminate. You may
modify or revoke an authorization at any time.
However, if we are unable to fulfill our
requirements related to treatment, payment or health
care operations, we may choose to discontinue
providing you with health care treatment and
use or disclose health information about you without
your permission for the following purposes, subject
to all applicable legal requirements and
Avert a Serious Threat to Health or Safety.
Based on professional judgment, we may use and
disclose health information about you when necessary
to prevent a serious threat to your health and
safety or the health and safety of the public or
Required By Law.
Based on professional judgment, we will disclose
health information about you when required to do so
by federal, state, or local law. Disclosures may be
compelled by the Department of Health and Human
Services for compliance and enforcement purposes.
Lawsuits and Disputes.
If you are involved in a lawsuit or a dispute, we
may disclose health information about you in
response to a court or administrative order.
We may release health information if required to do
so by a law enforcement official in response to a
court order, subject to all applicable legal
In situations where you are not capable of giving
authorization (because you are not present or due to
your incapacity or medical emergency), we may, using
our professional judgment, determine that a
disclosure to your family member or friend is in
your best interest. In that situation, we would
disclose only health information relevant to the
person's involvement in your care. For example, if
you were in a mental health crisis, we might involve
a family member or friend in helping you get to an
appropriate care facility.
Additional disclosures are permitted under HIPAA
regulation. These additional disclosures will not be
made without your authorization; and they may be
contrary to state law. However, once information
leaves this practice and becomes part of any data
resource beyond our control, HIPAA permits
disclosure in the following circumstances:
Health information about you can be used for
research projects that are subject to a special
approval process. You may be asked for your
permission, if the researcher will have access to
your name, address, or other information that
reveals who you are.
Military, Veterans, National Security, and
If you are or were a member of the armed forces, or
part of the national security or intelligence
communities, military command or other government
authorities may require the release of health
information about you. HIPAA also permits release of
information about foreign military personnel to the
appropriate foreign military authority.
Health information about you may be released for
workers' compensation or similar programs. These
programs provide benefits for work-related injuries
Health information about you may be disclosed for
public health reasons in order to prevent or control
disease, injury, or disability; or report births,
deaths, suspected abuse or neglect, non-accidental
physical injuries, reactions to medications, or
problems with products.
Health information about you may be disclosed to a
health oversight agency for audits, investigations,
inspections, or licensing purposes. These
disclosures may be necessary for certain state and
federal agencies to monitor the health care system,
government programs, and compliance with civil
Information Not Personally Identifiable.
Health information about you may be disclosed in a
way that does not personally identify you or reveal
who you are.
USES AND DISCLOSURES OF HEALTH INFORMATION
practice will not use or disclose your health
information for any purpose other than those
identified in the previous sections without your
specific, written Authorization. We must obtain your
Authorization separate from any Consent we may have
obtained from you. If you give us Authorization to
use or disclose health information about you, you
may revoke that Authorization, in writing, at any
time. If you revoke your Authorization, we will no
longer use or disclose information about you for the
reasons covered by your written Authorization, but
we cannot take back any uses or disclosures already
made with your permission. If we have HIV or
substance abuse information about you, we cannot
release that information without a special signed,
written authorization (different than the
Authorization and Consent mentioned above) from you.
In order to disclose these types of records for
purposes of treatment, payment, or health care
operations, we will require a special written
authorization that complies with the law governing
HIV or substance abuse records.
RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
have the following rights regarding health
information we maintain about you:
to Inspect and Copy.
You have the right to inspect and copy your health
information, such as clinical and billing records.
You do not have the right to inspect and copy
psychotherapy notes or information compiled in
reasonable anticipation of, or for use in, a civil,
criminal, or administrative action or proceeding.
You must submit a written request to the designated
privacy contact in order to inspect and/or copy your
health information. If you request a copy of the
information, we may charge a fee for the costs of
copying, mailing, or other associated supplies. We
may deny your request to inspect and/or copy in
certain limited circumstances. If you are denied
access to your health information, you may ask that
the denial be reviewed. If such review is required
by law, we will select a licensed health care
professional to review your request and our denial.
The person conducting the review will not be the
person who denied your request, and we will comply
with the outcome of the review.
If you believe health information we have about you
is incorrect or incomplete, you may ask us to amend
the information. You have the right to request an
amendment when the information is kept by this
office. To request an amendment, complete and submit
a clear statement of the amendment you request to
the designated privacy contact. 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:
did not create, unless the person or entity that
created the information is no longer available
to make the amendment
not part of the health information that we keep
You would not be permitted to inspect and copy
accurate and complete
if we deny your request for amendment, you have the
right to submit a written addendum, not to exceed
250 words, with respect to any item or statement in
your record you believe is incomplete or incorrect.
If you clearly indicate in writing that you want the
addendum to be made part of your medical record we
will attach it to your records and include it
whenever we make a disclosure of the item or
statement you believe to be incomplete or incorrect.
to an Accounting of Disclosures.
You have the right to request an accounting of
disclosures. This is a list of the disclosures we
made of clinical information about you for purposes
other than treatment, payment and health care
operations. To obtain this list, you must submit
your request in writing to the designated privacy
contact. Your request must state a time period,
which may not be longer than six years and may not
include dates before July 1, 2006. Your request
should indicate in what form you want the list (for
example, on paper, electronically). The first list
you request within a 12-month period will be free.
For additional lists, we may charge you for the
costs of providing the list. We will notify you of
the cost involved, and you may choose to withdraw or
modify your request at that time before any costs
to Request Restrictions.
You have the right to request a restriction or
limitation on the health information we use or
disclose about you for treatment, payment, or health
care operations. You also have the right to request
a limit on the health information we disclose about
you to someone who is involved in your care or the
payment for it, like a family member or friend. For
example, you could ask that we not call you at your
office, or that we not communicate with a certain
family member, no matter what the circumstance. We
are not required to agree to your request. If we do
agree, we will comply with your request unless the
information is needed to provide you emergency
treatment. To request restrictions, you may simply
advise us in writing of specific limitations or
restrictions you want placed on our use of health
information for treatment, payment or healthcare
operations. We will not ask you the reason for your
request. We will accommodate all reasonable
to Request Confidential Communications.
You have the right to request that we communicate
with you about clinical matters in a certain way or
at a certain location. For example, you can ask that
we only contact you at work or by mail. To request
confidential communications, you may simply advise
us in writing of specific limitations or
restrictions you want placed on our communications
with you. We will not ask you the reason for your
request. We will accommodate all reasonable
requests. Your request must specify how or where you
wish to be contacted.
to a Paper Copy of This Notice.
You have the right to a paper copy of this notice.
You may ask us to give you a copy of this notice at
any time. Even if you have agreed to receive it
electronically, you are still entitled to a paper
copy. To obtain such a copy, contact the designated
CHANGES TO THIS NOTICE We reserve the right to change this notice, and to
make the revised or changed notice effective for
clinical information we already have about you as
well as any information we receive in the future. We
will post a summary of the current notice with its
effective date clearly shown at the top. You are
entitled to a copy of the notice currently in
effect. You may ask to be mailed a paper copy of
this notice by requesting one from Dr. J. Davis
Martin, LPC (privacy contact), by email at
or in writing at P. O. Box 70245, Montgomery, AL
believe your privacy rights have been violated, you
may file a complaint with us or with the Secretary
of the Department of Health and Human Services. To
file a complaint with us, write to our designated
privacy contact. You will not be penalized for
filing a complaint.
are ready to begin eTherapy, please go to the
section of this site.