1800 Town Center Drive, Suite 411
Reston Virginia 20190




The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) requires
that all medical records and other individually identifiable health information used
or disclosed by us in any form are kept confidential.  This Act gives you, the patient,
significant new rights to understand and control how your health information is used.
  “HIPAA” provides penalties for covered entities that misuse personal health information.

 Reston Psychological Center (RPC) may use and disclose your protected health information
(PHI) only for each of the following purposes with your consent: treatment, payment and health
care operations.

·         Treatment means providing, coordinating, or managing your health care and related services
by one or more health care providers.

·         Payment means such activities as obtaining reimbursement for services, confirming coverage,
billing or collection activities, and utilization review.

·         Health Care Operations are activities that relate to the performance and operation of our
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 RPC’s office, such as sharing, employing, applying, utilizing,
examining, and analyzing information that identifies you.

Disclosure” applies to activities outside of RPC’s office, such as releasing, transferring, or providing
access to information about you to other parties.

“PHI” – Protected Health Information refers to information in your health record that could identify you.

 Uses and Disclosures Requiring Authorization

RPC 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 RPC  is
asked for information for purposes outside of treatment, payment and health care operations, we will
obtain an authorization from you before releasing this information.  RPC will also need to obtain an
authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes a therapist
has made about conversations during a private, group, joint, or family counseling session, which is 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) RPC  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.

 Uses and Disclosures with Neither Consent nor Authorization

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

§         If a therapist has reason to suspect that a child or an adult is abused or neglected or exploited,
the therapist is required by law to report the matter immediately to the Department of Welfare or Social Services.

§         The Board of Psychology and the Board of Social Work have the power, when necessary,
to subpoena relevant records.

·          If in a court proceeding, a request is made for information about your diagnosis and
treatment and the records thereof, such information is privileged under state law, and RPC will
not release information without the written authorization of you or your legal representative, or a
subpoena.  However, if you move to quash (block) the subpoena, RPC  is  required to place said
records in a sealed envelope and provide them to the clerk of court 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.

·         If a client communicates a specific and immediate threat to cause serious bodily injury or
death, to an identified or to an identifiable person, and the therapist believes the client has the intent
and ability to carry out that threat, the therapist 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.

§         If you file a worker's compensation claim RPC is required by law, upon request,
to submit your relevant mental health information to you, your employer, the insurer, or a
certified rehabilitation provider.

 Patient’s Rights:

·         You have the right to request restrictions on certain uses and disclosures of protected
health information about you. However,  RPC is not required to agree to a restriction which you request.

·         You have the right to request and receive confidential communications of PHI by alternative
means and at alternative locations.  Upon your request, we will send your bills to another address.

·         You have the right to inspect or obtain a copy of PHI and psychotherapy notes as long as
the PHI is maintained in the record. RPC may deny your access to PHI under certain circumstances,
but in some cases you may have this decision reviewed. On your request, your therapist will discuss
with you the details of the request and denial process.

·         You have the right to request an amendment of PHI for as long as the PHI is maintained in
the record.  RPC may deny your request.  Your therapist can discuss with you the details of the
amendment process.

·         You generally have the right to receive an accounting of disclosures of PHI for which you
have not provided consent. On your request, your therapist will discuss with you the details of the
accounting process.

·         You have the right to obtain a paper copy of this notice upon request, even if you have
agreed to receive the notice electronically.

 This notice is effective as of April 14, 2003, and RPC is required to abide by the terms of the Notice of
Privacy Practices currently in effect.  We reserve the right to change the terms of our Notice of Privacy
Practices and to make the new notice provisions effective for all protected health information that we maintain. 
We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

If you feel that your privacy protections have been violated, you have the right to file a written complaint
with our office or with the Department of Health & Human Services, Office of Civil Rights, about violations
of the provisions of this notice or the policies and procedures of our office.