Notice from Frederick A. Levy LCSW:
Policies and Practices to Protect the Privacy of Your Health Information

This NOTICE describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Your provider or a representative may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

  • “PHI” refers to information in your health record that could identify you.
  • “Treatment, Payment and Health Care Operations”
    • Treatment is when your provider provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when your provider consults with another health care provider, such as your family physician or a therapist.
    • Payment is when your provider obtains reimbursement for your healthcare. Examples of payment are when your provider or representative discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
    • Health Care Operations are activities that relate to the performance and operation of this practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
    • “Use” applies only to activities within this office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  • “Disclosure” applies to activities outside of this office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

Your provider may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when your provider is asked for information for purposes outside of treatment, payment and health care operations, he/she will obtain an authorization from you before releasing this information. He/she will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes made about your conversations during a private, group, joint, or family counseling session, which are kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) your provider already has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

Your provider may use or disclose PHI without your consent or authorization in the following circumstances:

  • Child Abuse: If your provider has reason to suspect that a child is abused or neglected, he/she is required by law to report the matter immediately to the Virginia Department of Social Services.
  • Adult and Domestic Abuse: If your provider has reason to suspect that an adult is abused, neglected or exploited, he/she is required by law to immediately make a report and provide relevant information to the Virginia Department of Welfare or Social Services.
  • Health Oversight: The Boards under the Department of Health Professions have the power, when necessary, to subpoena relevant records should your provider be the focus of an inquiry.
  • Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and will not be released without the written authorization of you or your legal representative, or a subpoena (of which you have been served, along with the proper notice required by state law). However, if you move to quash (block) the subpoena, your provider is required to place said records in a sealed envelope and provide them to the Clerk of Court of the appropriate jurisdiction so that the court can determine whether the records should be released. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
  • Serious Threat to Health or Safety: If your provider is engaged in his/her professional duties and you communicate to him/her a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and it is believed that you have the intent and ability to carry out that threat immediately or imminently, your provider must take steps to protect third parties. These precautions may include (1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18; or (2) notifying a law enforcement officer.
  • Worker’s Compensation: If you file a worker's compensation claim, your provider is required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
  • Health Care Violations: If you provide evidence that a health care professional may have violated laws, regulations, or standards of competent care, or if you as a health care professional in treatment brings into question your competence to practice, then your provider may be required by law to inform the appropriate regulatory Board.

IV. Patient's Rights and Provider’s Duties

Patient’s Rights:

  • 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. (For example, you may not want a family member to know that you are in treatment. Upon your request, your bills will be sent to another address.)
  • Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in your provider’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your provider may deny you access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, the details of the request and denial process will be discussed with you.
  • Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your provider may deny your request. On your request, the details of the amendment process will be discussed with you.
  • Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, the details of the accounting process will be discussed with you.
  • Right to a Paper Copy – You have the right to obtain a paper copy of the notice from this office upon request, even if you have agreed to receive the notice electronically.

Provider’s Duties:

  • Your provider is required by law to maintain the privacy of PHI and to provide you with a notice of his/her legal duties and privacy practices with respect to PHI.
  • Frederick A. Levy LCSW reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, we are required to abide by the terms currently in effect.
  • If these policies and procedures are revised, Frederick A. Levy LCSW will place such revisions in the waiting room and will post them on my website at

V. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Frederick A. Levy LCSW at (757) 873-1240. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. To file a complaint with the Secretary of Health and Human Services call or write to:

Region III OCR
Health and Human Services
150 S. Independence Mall West
Suite 372
Philadelphia, PA 19106-9111
(215) 861-4441 Main Line
(800) 368-1019 Hot Line
(215) 861-4431 Fax
(215) 861-4440 TDD

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on April 14th, 2003.

Frederick A. Levy LCSW reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that are maintained by this practice. A revised notice will be provided in the waiting room and posted on our website.

Revised 04/14/03