Notice of Privacy Practices
Effective Date: February 16, 2026
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.
___________________
Your Protected Health Information
Your health record contains personal information about you and your health. State and Federal law protect the confidentiality of this information. “Protected Health Information” (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services.
I am required by law to maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy practices with respect to your PHI. This Notice describes how I may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI.
I am required to abide by the terms of this Notice. I reserve the right to change the terms of this Notice at any time. Any revised Notice will apply to all PHI I maintain at that time. A revised Notice will be made available to you electronically, or by mail upon request.
___________________
How I May Use and Disclose Your PHI
For Treatment
I may use and disclose medical and clinical information about you to provide you with treatment services. This may include consultation, supervision, referral, or coordination of care with other healthcare providers.
For Payment
I may use and disclose medical information about you so that I may receive payment for the services provided. This may include disclosures to insurance companies or collection agencies for unpaid balances.
For Health Care Operations
I may use and disclose your PHI to support the operation of my professional practice. This includes supervision, consultation, quality assurance, peer review, administrative, legal, financial, or business services. I will have written agreements with business associates requiring them to safeguard your PHI.
Incidental Uses and Disclosures
A use or disclosure that occurs incidentally to an otherwise permitted use or disclosure is allowed if reasonable safeguards are in place and the information disclosed is limited to the minimum necessary.
___________________
Special Confidentiality for Substance Use Disorder (SUD) Treatment Records
Certain records created or received by this practice relating to the diagnosis, treatment, or referral for treatment of a substance use disorder are protected by a federal law known as 42 CFR Part 2, in addition to HIPAA and Washington State law. These are referred to as “SUD treatment records.”
Uses and Disclosures of SUD Treatment Records
SUD treatment records may be used and disclosed for treatment, payment, and health care operations as permitted by federal law. However, these records receive heightened confidentiality protections.
Except as permitted by law, I may not disclose SUD treatment records without your written authorization.
Limited exceptions where disclosure may occur without your authorization include:
Medical emergencies
Public health reporting as authorized by law
Research that complies with federal regulations
Audit and evaluation activities
Court orders that specifically comply with 42 CFR Part 2
Prohibition on Redisclosure
Federal law generally prohibits recipients of SUD treatment records from redisclosing them unless expressly permitted by your written authorization or by 42 CFR Part 2. Unauthorized disclosure may result in criminal penalties.
Use in Legal Proceedings
SUD treatment records may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you without your specific written consent or a court order that complies with 42 CFR Part 2.
Additional Rights Related to SUD Records
In addition to your HIPAA rights, you have the following rights regarding SUD treatment records:
You may request an accounting of disclosures of SUD treatment records for treatment, payment, and health care operations made within three (3) years prior to your request.
You may revoke a written authorization at any time, except to the extent I have already relied upon it.
You may request restrictions on certain disclosures.
___________________
Other Uses and Disclosures That Do Not Require Authorization
Required by Law
I may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. Examples of this type of disclosure include healthcare licensure related reports, public health reports, and law enforcement reports. Under the law, I must make certain disclosures of your PHI to you upon your request. In addition, I must make disclosures to the US Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of privacy rules.
Health Oversight
I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors) and peer review organizations performing utilization and quality control. If I disclose PHI to a health oversight agency, I will have an agreement in place that requires the agency to safeguard the privacy of your information.
Abuse or Neglect
I may disclose your PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect. However, the information we disclose is limited to only that information which is necessary to make the required mandated report.
Deceased Clients
I may disclose PHI regarding deceased clients for the purpose of determining the cause of death, in connection with laws requiring the collection of death or other vital statistics, or permitting inquiry into the cause of death.
Research
I may disclose PHI to researchers if (a) an Institutional Review Board reviews and approves the research and a waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; and (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations.
Criminal Activity or Threats
I may disclose your PHI if I reasonably believe that the disclosure will avoid or minimize an imminent threat to the health or safety of yourself or any third party.
Compulsory Process
I may be required to disclose your PHI if a court of competent jurisdiction issues an appropriate order, and if the rule of privilege has been determined not to apply. I may be required to disclose your PHI if I have been notified in writing at least fourteen days in advance of a subpoena or other legal demand, no protective order has been obtained, and a competent judicial officer has determined that the rule of privilege does not apply. Disclosures of SUD treatment records are subject to additional federal restrictions described above.
Essential Government Functions
I may be required to disclose your PHI for certain essential government functions. Such functions include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs.
Law Enforcement Purposes
I may be authorized to disclose your PHI to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person’s death, if I suspect that criminal activity caused the death; (5) when I believe that protected health information is evidence of a crime that occurred on my premises; and (6) in a medical emergency not occurring on my premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.
___________________
Psychotherapy Notes
If maintained separately, I must obtain your authorization to use or disclose psychotherapy notes with the following exceptions. I may use the notes for your treatment. I may also use or disclose, without your authorization, the psychotherapy notes for my own training, to defend myself in legal or administrative proceedings initiated by you, as required by the Washington Department of Health or the US Department of Health and Human Services to investigate or determine my compliance with applicable regulations, to avoid or minimize an imminent threat to anyone’s health or safety, to a health oversight agency for lawful oversight, for the lawful activities of a coroner or medical examiner or as otherwise required by law.
___________________
Uses and Disclosures With Your Written Authorization
Other uses and disclosures of your PHI will be made only with your written authorization. I will not sell your PHI or use it for marketing without your written authorization. You may revoke your authorization in writing at any time, except to the extent I have already relied upon it.
___________________
Your Rights Regarding Your PHI
You have the following rights regarding PHI that I maintain about you. A brief description of how you may exercise these rights is included. Any requests with respect to these rights must be in writing.
Right of Access to Inspect and Copy
You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as I maintain the record. A "designated record set" contains medical and billing records and any other records that I use for making decisions about you. Your request must be in writing. I may charge you a reasonable cost-based fee for the copying and transmitting of your PHI. I can deny you access to your PHI in certain circumstances. In some of those cases, you will have a right of recourse to the denial of access. Please contact me if you have questions about access to your medical record.
Right to Amend
You may request, in writing, that I amend your PHI that has been included in a designated record set. In certain cases, I may deny your request for an amendment. If I deny your request for amendment, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
Right to an Accounting of Disclosures
You may request an accounting of disclosures made for treatment purposes or made as a result of your authorization, for a period of up to six (6) years, excluding disclosures made to you. I may charge you a reasonable fee if you request more than one accounting in any 12-month period.
For SUD treatment records, you may request an accounting of disclosures for treatment, payment, and health care operations made during the three (3) years prior to your request.
Right to Request Restrictions
You have the right to ask me not to use or disclose any part of your PHI for treatment, payment or health care operations or to family members involved in your care. Your request for restrictions must be in writing and I am not required to agree to such restrictions. Please contact me if you would like to request restrictions on the disclosure of your PHI. You also have the right to restrict certain disclosures of your PHI to your health plan if you pay out of pocket in full for the health care I provide to you.
Right to Confidential Communications
You have the right to request to receive confidential communications from me by alternative means or at an alternative location. I will accommodate reasonable written requests. I may also condition this accommodation by asking you for information regarding how payment will be handled or specification of an alternative address or other method of contact. Please contact me if you would like to make this request.
Right to a Copy of This Notice
You have the right to obtain a copy of this notice from me. Any questions you have about the contents of this document should be directed to me.
Right to Revoke Consent (Part 2)
You may revoke your written consent at any time, except to the extent I have already relied on it.
Right to Opt Out
You have the right to choose not to receive fundraising communications. However, I will not contact you for fundraising purposes.
Right to Notice of Breach
You have the right to be notified of any breach of your unsecured PHI.
___________________
Complaints
If you believe your privacy rights have been violated, you may file a complaint with me in writing. You may also file a complaint with:
The Washington State Department of Health
The U.S. Secretary of Health and Human Services
You will not be retaliated against for filing a complaint.
___________________
Contact Information
I act as my own Privacy and Security Officer. If you have questions about this Notice or wish to exercise any of your rights, please contact:
Darby Robertson
Address: 614 W McGraw St, Suite 204, Seattle, WA 98119
Phone: (206) 627-0874
Email: darby@deeproots-counseling.com