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Notice of Privacy Practices

This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.

HIPAA requires that your provider gives you Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, explains HIPAA and its application to your PHI in greater detail.

The law requires that your provider obtains your signature acknowledging that your provider has provided you with this.  If you have any questions, it is your right and obligation to ask so your provider can have a further discussion prior to signing this document.  When you sign this document, it will also represent an agreement between you and your provider.  You may revoke this agreement in writing at any time.  That revocation will be binding unless your provider have taken action in reliance on it.


The law protects the privacy of all communication between a patient and a therapist.  In most situations, your provider can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA.  There are some situations where your provider is permitted or required to disclose information without either your consent or authorization. If such a situation arises, your provider will limit their disclosure to what is necessary.  Reasons your provider may have to release your information without authorization:

  • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the provider-patient privilege law. Your provider cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if your provider receives a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena.  If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order your provider to disclose information.

  • If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, your provider may be required to provide it for them.

  • If a patient files a complaint or lawsuit against your provider, your provider may disclose relevant information regarding that patient in order to defend themselves.

  • If a patient files a worker's compensation claim, and your provider gives necessary treatment related to that claim, your provider must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider.

  • Your provider may disclose the minimum necessary health information to their business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  The provider’s business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.


There are some situations in which your provider is legally obligated to take actions, which they believe are necessary to attempt to protect others from harm, and your provider may have to reveal some information about a patient's treatment:

  • If your provider knows, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that your provider file a report with the Wisconsin Abuse Hotline or the local hotline.  Once such a report is filed, your provider may be required to provide additional information.

  • If your provider knows or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with Wisconsin Abuse Hotline or the local hotline.  Once such a report is filed, your provider may be required to provide additional information.

  • If your provider believes that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, your provider may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.



Use and Disclosure of Protected Health Information:

  • FOR TREATMENT: You provider uses and discloses your health information internally in the course of your treatment.  If your provider wishes to provide information outside of the agency for your treatment by another health care provider, your provider will have you sign an authorization for release of information.  Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.

  • FOR PAYMENT: Your provider may use and disclose your health information to obtain payment for services provided to you as delineated in the “Consent for Treatment, Policies and Agreement” Policy.

  • FOR OPERATIONS: Your provider may use and disclose your health information as part of our internal operations.  For example, this could mean a review of records to assure quality.  Your provider may also use your information to tell you about services, educational activities, and programs that your provider feels might be of interest to you.



  • RIGHT TO TREATMENT: You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.

  • RIGHT TO CONFIDENTIALITY: You have the right to have your health care information protected.  If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. Your provider will agree to such unless a law requires you and your provider to share that information.

  • RIGHT TO REQUEST RESTRICTIONS: You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, your provider is not required to agree to a restriction you request.

  • RIGHT TO RECEIVE CONFIDENTIAL COMMUNICATIONS BY ALTERNATIVE MEANS AND AT ALTERNATIVE LOCATIONS: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.

  • RIGHT TO INSPECT AND COPY: You have the right to inspect or obtain a copy (or both) of PHI.  Records must be requested in writing and release of information must be completed.  Please see the “Consent for Treatment, Policies and Agreement” for associated fees and notices.  If your provider refuses your request for access to your records, you have a right of review, which your provider will discuss with you upon request.

  • RIGHT TO AMEND: If you believe the information in your records is incorrect and/or missing important information, you can ask your provider to make certain changes, also known as amending, to your health information.  You have to make this request in writing.  You must tell your provider the reasons you want to make these changes, and your provider will decide if it is and if your provider refuses to do so, they will tell you why within 60 days of processing their decision.

  • RIGHT TO A COPY OF THIS NOTICE: If you received the paperwork electronically, you have a copy in your client portal or email.  If you completed this paperwork in the office, a copy will be provided to you per your request.

  • RIGHT TO AN ACCOUNTING: You generally have the right to receive an accounting of disclosures of PHI regarding you.  On your request, your provider will discuss with you the details of the accounting process.

  • RIGHT TO CHOOSE SOMEONE TO ACT FOR YOU: If someone is your legal guardian, that person can exercise your rights and make choices about your health information; your provider will make sure the person has this authority and can act for you before your provider takes any action.

  • RIGHT TO CHOOSE: You have the right to decide not to receive services with me.  If you wish, your provider will provide you with names of other qualified professionals.

  • RIGHT TO TERMINATE: You have the right to terminate therapeutic services with your provider at any time without any legal or financial obligations other than those already accrued. You provider asks that you discuss your decision with them in session before terminating or at least contact them by phone letting me know you are terminating services.

  • RIGHT TO RELEASE INFORMATION WITHOUT WRITTEN CONSENT: With your written consent, any part of your record can be released to any person or agency you designate.  Together, your provider will discuss whether or not they think releasing the information in question to that person or agency might be harmful to you.



Your provider is required by law to maintain the privacy of PHI and to provide you with a notice of their legal duties and privacy practices with respect to PHI.  Your provider reserves the right to change the privacy policies and practices described in this notice.  Unless your provider notifies you of such changes; however, they are required to abide by the terms currently in effect.  If they revise their policies and procedures, they will provide you with a revised notice electronically or in office.



If you are concerned that your provider has violated your privacy rights, or you disagree with a decision they made about access to your records, you may contact them, the State of Wisconsin Department of Health, or the Secretary of the U.S. Department of Health and Human Services.

Reviewed/Updated: January 1, 2023

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