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Notice of Privacy Practices


Effective 9/1/13




I am required by law to protect the privacy of your health information and to notify you in there is a breach of your unsecured protected health information.  I am also required to provide you this notice, which explains how I may use information about you and when I can give out or “disclose” that information to others.  You also have rights regarding your health information that are described in this notice.  I am required by law to abide by the terms of this notice.


The terms “information” or “health information” in this notice include any information I maintain that reasonably can be used to identify you and that relates to you behavioral health condition, the provision of health care to you, or the payment of such care.


I have the right to change my privacy practices and the terms in this notice.  If I make a material change to my privacy practices, I will update this notice.  You may receive the most recent copy of the Notice by calling and asking for it, or by visiting my office to pick one.  In all cases, I will post the revised notice on my website at  I reserve the right to make any revised or changed notice effective for information we already have and for information I receive in the future.




I must use and disclose your health information to provide that information:


  • To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice: and

  • To the Secretary of the Department of Health and Human Services, if necessary, to make sure you privacy is protected.


I have the right to use and disclose health information for your treatment, to pay for health care services you receive, and to operate my business.  For example, I may disclose your health information:


  • For Treatment.  I may use or disclose health information to aid in your treatment or coordination of your care.

  • For Payment of premiums due to me and to determine your coverage.

  • For Heath Care Operations.    I may use or disclose health information as necessary to operate and manage my business activities related to providing and managing your health care.


I may use or disclose your health information for the following purposes under limited circumstances:


  • As Required or Allowed by Law.

  • For Health Oversight Activities

  • For Public Health Activities

  • For Disaster Relief Purposes.

  • To Report Suspected Abuse or Neglect.

  • For Judicial or Administrative Purposes

  • For Law Enforcement Purposes

  • To Correctional Institutions

  • For Specialized Government Functions

  • For Worker’s Compensation


  • For Research Purposes


  • To Coroners, Medical Examiners, or Funeral Directors

  • To Business Associates

  • For Date Breach Notification Purposes


Most Uses and Disclosures or psychotherapy notes, uses and disclosures of protected health information for marketing purposes, and disclosures that constitute a sale of protected health information require your authorization.  Other uses and disclosures not described in the Notice will be made only with your written authorization.




The health and billing records I create and store at the property of Elizabeth Orchard, LICSW.  The health information in the records, however, generally belongs to you.  You have the right to:


  • Receive a paper copy of this Notice of Privacy Practices for Protected Health Information (“Notice”) from me.

  • Ask me to restrict uses or disclosures of the health information for treatment, payment or health care operations.  You must deliver this request in writing to myself, Elizabeth Orchard.  I am not required to grant the request, but will comply with any request granted.

  • Request that you be allowed to inspect and purchase a copy of your health record.  You must make this request in writing.

  • Cancel prior authorizations to use or disclose health information by giving me written notice.  You revocation does not affect information that has already been released.  It also does not affect any action taken before I have received the written revocation.

  • Request that I amend any of the health information used to make decisions about your care, including treatment or payment records.  To do so, you must submit a written request and tell me why you believe the information is incorrect.  I may deny your request for an amendment if it is not in writing or does not include a reason for the request.  I may also deny your request if you ask me to amend health information that:


  • Was not created by me, unless you provide a reasonable basis that the person or entity that created the health information is no longer available to act on your request

  • Is not part of the health information I maintain to  make decisions about your care;

  • Is not part of the health information that you would be permitted to inspect or copy; or

  • Is accurate and complete


If your request to amend your health information is denied, I will send you a letter stating the reason for the denial.  You may write a statement of disagreement if you request is denied.  You may ask that your requested amendment and our denial be attached to all future disclosures of the health information that is the subject of your request.  If you choose to submit a written statement of disagreement, I may prepare a written rebuttal to your statement of disagreement.  In this case, I will attach the written request and the rebuttal (as well as the original request and denial) to all future disclosures of the health information that is the subject of your request.


  • Request that I provide you with a list of disclosures I have made of your health information for the prior six years.  The list will not include certain disclosures of your health information such as those made for the purposes of treatment, payment, and health care operations or disclosures that you authorized in writing. 

  • Ask that I communicate with you about your health information by another means or at another location.  Please make your request in writing, sign and date it.  I will accommodate all reasonable requests.  You do not need to give me a reason for this request; but your request must specify how or where you wish to be contacted.


To Ask for Help or Complain


If you have questions, want more information, or want to report a problem about the handling of your information, you may contact myself, Elizabeth Orchard, at (2060 854-1828.


If you believe your privacy rights have been violated, you may deliver a written complain to 9500 Roosevelt Way NE, Suite 206, Seattle, WA  98115.  You may also file a complaint with the United States Secretary of Health and Human Services.


I respect your right to file a complaint with myself or with the Secretary of Health and Human Services.  If you choose to take this action, I will not retaliate against you.


I have a website that provides information about myself and my practice.  For your benefit, this Notice is on the website at



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