Notice of Privacy Practices

Notice of Privacy Practices



I am dedicated to protecting your medical information. A federal regulation, known as the “HIPAA Privacy Rule”, requires that I provide a detailed notice in writing of the privacy practices. Your Protected Health Information “PHI” is information that identifies you and relates to your past, present, or future health or condition, the provision of healthcare to you, or payment for that healthcare. I am required by law to maintain the privacy of your PHI and to give you this notice about the privacy practices that explains your rights as my patient and how, when, and why I may use or disclose your PHI.

I am required by law to follow the privacy practices described in this notice, though I reserve the right to change the privacy practices and the terms of this notice at any time and to apply those changes to all PHI in my possession. If I change the privacy practices and the terms of this notice, I will post a copy in the clinic office in a prominent location, have copies of the revised notice available at the clinic office, and provide you with a copy of the revised notice upon your request.


This notice describes my practices regarding the use of your medical information and that of:

  • Any healthcare professional authorized to enter information into your medical chart or medical record, including without limitation, mental health providers, technicians, and psychologists.
  • All employees, staff and other personnel who may need access to your information.


Treatment, Payment and Healthcare Operations: As described below, I will use or disclose your PHI for treatment, payment, or healthcare operations. The examples below do not list every possible use or disclosure in a category.

  • Treatment: I may use and disclose PHI about you to provide, coordinate or manage your healthcare and related services. I may consult with other healthcare providers or psychologists regarding your treatment and coordinate and manage your healthcare with others. I may also use and disclose PHI about you when referring to a specialist regarding your symptoms. I may also disclose PHI about you for the treatment activities of another healthcare provider. For example, I may send a report about your care to another physician or mental health provider so that the other provider may treat you.
  • Payment: I may use and disclose PHI so that I can bill and collect payment for the treatment and services provided to you. For example, I may send your insurance company a bill for services or release certain medical information to your health insurance company so that it can determine whether your treatment is covered under the terms of your health insurance policy. I also may use and disclose PHI for billing, claims management, and collection activities. I may also disclose PHI to another healthcare provider or to a company or health plan required to comply with the HIPAA Privacy Rule for the payment activities of that healthcare provider, company, or health plan. For example, I may allow a health insurance company to review PHI relating to their enrollees to determine the insurance benefits to be paid for their enrollees’ care.
  • Healthcare Operations: I may use and disclose PHI in performing certain business activities which are called healthcare operations. Some examples of these operations include our business, accounting, and managements activities. These healthcare operations also may include quality assurance, utilization review, and internal auditing, such as auditing and reviewing and evaluating the skills, qualifications, and performance of healthcare providers taking care of you and other patients and providing training programs to help students develop or improve their skills. If another healthcare provider, company, or health plan that is required to comply with the HIPAA Privacy Rule has or once had a relationship with you, we may disclose PHI about you for certain healthcare operations of that healthcare provider or company. For example, such healthcare operations may include assisting with legal compliance activities of that healthcare provider or company.
  • Communications to You From My Office: I may use or disclose medical information in order to contact you as a reminder that you have an appointment for treatment or other medical care, to tell you about or recommend possible treatment options or alternatives that may be of interest to you, or to inform you about health related benefits or services that may be of interest to you.
  • Communications to Family or Friends If You Agree or Do Not Object: I may disclose PHI to your relatives, close friends or any other person identified by you if the PHI is directly related to that person’s involvement in your care or payment for your care. Generally, except in emergency situations, I will inform you of the intended action prior to making any such uses and disclosures and will, at that time, offer you the opportunity to object. However, if you are not present or are unable to agree or object to such a disclosure, I may disclose such information as necessary if I determine that it is in your best interest based on my professional judgment. I may also use and disclose your health information for the purpose of locating and notifying your relatives or close personal friends of your location, general condition or death, and to organizations that are involved in those tasks during disaster situations.
  • Other Uses and Disclosures Authorized by the HIPAA Privacy Rule. When disclosure complies with my professional confidentiality and ethical requirements, I may use and disclose PHI about you in the following circumstances, provided that we comply with certain legal conditions set forth in the HIPAA Privacy Rule.
  • Required By Law. I may use or disclose PHI as required by federal, state, or local law if the disclosure complies with the law and is limited to the requirements of the law.
  • Public Health Activities. I may disclose PHI to public health authorities or other authorized persons to carry out certain activities related to public health.
  • Abuse, Neglect, or Domestic Violence. I may disclose PHI to proper government authorities if I reasonably believe that a patient has been a victim of domestic violence, abuse, or neglect.
  • Health Oversight. I may disclose PHI to a health oversight agency for oversight activities including, for example, audits, investigations, inspections, licensure and disciplinary activities and other activities conducted by health oversight agencies to monitor the healthcare system, government healthcare programs, and compliance with certain laws.
  • Legal Proceedings. I may disclose PHI as expressly required by a court or administrative tribunal order or in compliance with state law. I also may disclose PHI in response to subpoenas, discovery request or other legal process when I receive satisfactory assurances that efforts have been made to advise you of the request or to obtain an order protecting the information requested.
  • Law Enforcement. I may disclose PHI to law enforcement officials under certain specific conditions, as authorized by law.
  • Coroners, Medical Examiners, or Funeral Directors. I may disclose PHI regarding a deceased patient to a coroner, medical examiner or funeral director so that they may carry out their jobs. I also may disclose such information to a funeral director in reasonable anticipation of a patient’s death.
  • Organ Donation. I may disclose PHI to organizations that help procure, locate, and transplant organs in order to facilitate organ, eye, or tissue donation and transplantation.
  • Threat to Health or Safety. In limited circumstances, I may disclose PHI when I have a good faith belief that the disclosure is necessary to prevent a serious and imminent threat to the health or safety of a person or to the public.
  • Specialized Government Functions. I may disclose PHI for certain specialized government functions, such as military and veteran activities, national security and intelligence activities, protective services for the president and others, medical suitability determinations, and for certain correctional institutions or in other law enforcement custodial purposes.
  • Compliance Review. I am required to disclose PHI to the Secretary of the United State Department of Health and Human Services when requested by the Secretary to review my compliance with the HIPAA Privacy Rule.
  • Workers’ Compensation. I may disclose PHI in order to comply with laws relating to workers’ compensation or other similar programs.
  • Research. For research purposes under certain limited circumstances for research projects that have been evaluated and approved through an approval process that takes into account patients’ need for privacy. I must obtain a written authorization to use and disclose PHI about you for research purposes except in situations where a research project meets specific, detailed criteria established by the HIPAA Privacy Rule to ensure the privacy of PHI.

Emergencies. I may use or disclose your PHI in an emergency treatment situation in compliance with applicable laws and regulations.

With Your Written Authorization. All other uses and disclosure of your PHI will be made with only your written authorization. If you have authorized me to use or disclose PHI about you, you may revoke your authorization at any time, except to the extent I have taken action based on the authorization.

  • Psychotherapy Notes. A separate and specific authorization is required before I release your Psychotherapy Notes. Psychotherapy Notes are notes kept regarding specific conversations or impressions 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 protections than PHI. In some cases it is not appropriate for Psychotherapy Notes to be disclosed to anyone and in such a case we may decline to disclose them.


The HIPAA Privacy Rule gives you several rights with regard to your PHI. These rights include:

Right to Request Restrictions: You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or healthcare operations, or that I disclose to those who may be involved in your care or payment for your care. While I will consider your request, I am not required to agree to it. If I do agree to your request, I will comply with your request except as required by law or for emergency treatment. To request restrictions, you must make your request on the Request for Additional Privacy Form to the Privacy Officer.

Right to Receive Confidential Communications: You have the right to request that you receive communications regarding PHI in a certain manner or at a certain location. For example, you may request that I contact you at home, rather than at work. You must make your request in writing by submitting the Request for Alternative Communication Form specifying how you would like to be contacted (for example, by regular mail to your post office box and not your home) to the Privacy Officer. I will accommodate all reasonable requests.

Right to Inspect and Copy: You have the right to inspect and receive a copy of your PHI contained in records I maintain that may be used to make decisions about your care. These records usually include your medical and billing records but do not include psychotherapy notes; information gathered or prepared for a civil, criminal or administrative proceeding; or PHI that is subject to law that prohibits access. To inspect and copy your PHI, please contact the Privacy Officer at the address on the last page of this Notice. If you request a copy of the PHI about you, I may charge you a reasonable fee for the copying, postage, labor, and supplies used in meeting your request. I may deny your request to inspect and copy PHI only under limited circumstances, and in some cases, a denial of access may be reviewable.

Right to Amend: If you feel that medical information I have about you is incorrect or incomplete, you may ask me to amend the information for as long as such information is kept by or for me. You must submit your request to amend in writing to the Privacy Officer and give a reason for your request. I may deny your request in certain cases. If your request is denied, you may submit a written statement disagreeing with the denial, which I will keep on file and distribute with all future disclosure of the information to which it relates.

Right to Receive an Accounting of Disclosures: You have the right to request a list of certain disclosures of PHI made by me during a specified period of time. If you wish to make such a request, please contact the Privacy Officer. The first accounting that you request in a 12-month period will be free, but I may charge you for reasonable costs of providing additional lists in the same 12-month period. I will tell you about these costs, and you may choose to cancel your request at any time before costs are incurred.

Right to a Paper Copy of this Notice: You have a right to receive a paper copy of this notice at any time. To obtain a paper copy of this notice, please contact the Privacy Officer.


If you believe your privacy rights have been violated, you may file a complaint with this office, or with the Secretary of the United States Department of Health and Human Services. To file a complaint with this office, please contact the Privacy Officer. I will not take action against you or retaliate against you in any way for filing a complaint.


If you have any questions or need additional information about this Notice, please contact the Privacy Officer.


You may contact the Privacy Officer at the following address and phone number:

Privacy Officer: Lavonna Latta
Clinic Address: 1 West Sunbridge Dr
Fayetteville, AR 72703
Phone: (479) 443-5575


This notice was first published April 14, 2003 and last updated May 15, 2015