Washington Pastoral Counseling Service’s 
NOTICE OF PRIVACY PRACTICES (Long Version)
Effective 4/15/03

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.

Privacy is a very important concern for all those who come to this office. It is also complicated because of federal and
state laws and our professional ethics. Because the rules are so complicated some parts of this Notice are quite detailed
and you will probably want to read them several times to understand them. If you have any questions our Privacy
Officer will be happy to help you. Her name and address are at the end of this Notice.
Contents of this notice:
A. Introduction
B. What we mean by your medical information
C. Privacy and the laws about privacy
D. How your protected health information can be used and shared
1. Uses and disclosures with your consent
a.The basic uses and disclosures - For treatment, payment, and health care operations (TPO)
b. Other uses and disclosures in health care
2. Uses and disclosures requiring your authorization
3. Uses and disclosures not requiring your consent or authorization
4. Uses and disclosures requiring you to have an opportunity to object
5. An Accounting of disclosures we have made
E. If you have questions or problems

A. Introduction
This notice will tell you about how we handle information about you. It tells how we use this information here in this
office, how we share it with other professionals and organizations, and how you can see it. We want you to know all of
this so that you can make the best decisions for you and your family. We are also required to tell you about this
because of the privacy regulations of a federal law, the Health Insurance Portability and Accountability Act of 1996
(HIPAA). Because of this law and the laws of this state are very complicated and we don’t want to make you read a lot
that may not apply to you, we have simplified some parts. If you have any questions or want to know more about
anything in this Notice, please ask our Privacy Officer for more explanation or details.


B. What We Mean by Your Medical Information
Each time you visit us, information is collected about your mental health. It may be information about your past,
present or future health or conditions, or the treatment or other services you got from us or from others, or about
payment for healthcare. This information is called, in the law, Protected Health Information, or PHI. This
information goes into your healthcare record or file at our office. Your PHI is likely to include these kinds of
information:
- Your history. As a child, in school and at work, and marital and personal history.
- Reasons you came for treatment. Your problems, complaints, symptoms, needs and goals.
- Diagnoses. - A treatment plan. 
- Progress notes. Each time you come in we write down some things about how you are doing, what we observe about
you, and what you tell us.
- Records we get from others who treated you or evaluated you.
- Psychological test scores, school records, etc.
- Information about medications you took or are taking. - Legal matters
- Billing and insurance information 

This is only a partial list. There may be other kinds of information that go into your healthcare record as well.

We use this information for many purposes. For example:
- To plan your care and treatment.
- To decide how well our treatments are working for you.
- When we talk with other healthcare professionals who are also treating you.
- To show that you actually received the services from us which we billed for.
- For public health officials trying to improve health care in this country.
- To improve the way we do our job by measuring the results of our work.

When you understand what is in your record and what it is used for you can make better decisions about who, when,
and why others should have this information.

Although your health record is the physical property of the healthcare practitioner or facility that collected it, the
information belongs to you. You can inspect, read, or review it. If you want a copy we can make one for you but we
may charge you for the costs of copying and mailing. In some very unusual situations you cannot see all of what is in
your records. If you find anything in your records that you think is incorrect or something important is missing you can
ask us to amend (add information to) your record. Although in some rare situations we don’t have to agree to do that.
Our privacy officer, whose name is at the end of this notice, can explain more about this.

C. Privacy and the Laws
The HIPPA law requires us to keep your PHI private and to give you this notice of our legal duties and our privacy
practices which is called the Notice of Privacy Practices or NPP (This is what you are reading right now). We will obey
the rules of this notice as long as it is in effect, but if we change it the rules of the new NPP will apply to all the PHI we
keep. If we change the NPP we will post the new Notice in our office where everyone can see it. You or anyone else
can also get a copy from our Privacy Officer at any time and it will be posted on our website at www.WPCS.org.

D. How Your Protected Health Information Can be Used and Shared
When your information is read by me or others in this office that is called, in the law, “use.” If the information is shared
with or sent to others outside this office, that is called, in the law, “disclosure.” Except in some special circumstances,
when we use your PHI here or disclose it to others we share only the minimum necessary PHI needed for the
purpose. The law gives you rights to know about your PHI, how it is used and to have a say in how it is disclosed and
so we will tell you more about what we do with your information.
We use and disclose PHI for several reasons. Mainly we will use and disclose (share) it for routine purposes
and we will explain more about these below. For other uses we must tell you about them and have a written 
authorization from you, unless the law lets or requires us to make the use or disclosure without your authorization.
However, the law also says that we are allowed to make some uses and disclosures without your
consent or authorization.

1. Uses and disclosures of PHI in healthcare with your consent
After you read this notice you will be asked to sign a separate Consent Form to allow us to use and share your PHI.
In almost all cases we intend to use your PHI here or share your PHI with other people or organizations to provide
treatment to you, arrange for payment for our services, or some other business functions called health care
operations. Together these routine purposes are called TPO and the Consent Form allows us to use and disclose your
PHI for TPO. Re-read that last sentence until it is clear because it is very important.

1a.  For treatment, payment, or health care operation
We need information about you and your conditions to provide care to you. You have to agree to let us collect
the information and to use it and share it as necessary to care for you properly. Therefore you must sign the Consent
Form before we begin to treat you because if you do not agree and consent we cannot treat you. Before you do please
read the following descriptions:
TREATMENT:
We use your treatment to provide you with psychological treatment or services. These might include individual,
family, or group therapy, psychological testing, treatment planning, or measuring the effects of our services. 
We may share or disclose your PHI to others who provide treatment to you for example, your physician, a case
manager, consultants on your care, other professionals we may refer you to or professionals you may see in the future.
Within our agency, to help ensure a high level of care, we have case conferences where a case is described and
feedback and suggestions are given from one’s colleagues. No identifying information is ever used. Some of our
counselors also receive clinical supervision where cases are discussed with a senior clinician.
PAYMENT:
After you have signed the Consent, I may use your information to bill you, your insurance or others. We may
contact your insurance company to check on exactly what your insurance company covers. We may have to tell them
about your diagnosis and what treatments we provide to you. We will need to tell them about when we met, your
progress and other similar things.
HEALTH CARE OPERATIONS
There are some others ways we may use or disclose your PHI which are called health care operations. For
example, we may use your PHI to see where we can make improvements in the care and services we provide. We may
be required to supply some information to some government health agencies so they can study disorders and treatment
and make plans for services that are needed. If we do, all names and other identifying information will be
removed.

1b. Other Uses in Healthcare
Appointments reminders:
We may use and disclose medical information to reschedule or remind you of appointments. If you want us to
call or write you only at your home or your work or prefer some other way to reach you, we can usually arrange that.
Just tell us.
Business Associates:
Some of our counselors use a billing service to receive payment from insurance companies. This company needs
to receive some of your PHI to do there job properly. To protect your privacy, they are also held to the same high
standards of privacy and confidentiality.


2. Uses and disclosures requiring your Authorization
If we want to use your information for any other purpose beside the TPO or those described above we need your
permission on an Authorization Form. We don’t expect to need this very often.
If you do authorize us to use or disclose your PHI, you can revoke (cancel) that permission, in writing, at any
time. After that time we will not use or disclose your information for the purposes that we agreed to. Of course, we
cannot take back any information we had already disclosed with your permission or that we had used in our office.

3. Uses and disclosures of PHI from mental health records not requiring Consent or Authorization
In some cases, the law requires or lets us use and disclose some of your PHI WITHOUT your consent or
authorization:
- We have to report suspected child or elder abuse
- If you are involved in a lawsuit or legal proceeding and we receive a subpoena, discovery request, or other lawful
process we may have to release some of your PHI. We will only do so after trying to tell you about the request,
consulting your lawyer, or trying to get a court to protect the information they requested.
-We may have to release some information to the government agencies which check on us to see that we are obeying
the privacy laws.
For Law Enforcement Purposes
We may release medical information if asked to do so by a law enforcement official to investigate a crime or criminal.
For Public Health Activities 
We might disclose some of your PHI to agencies which investigate diseases or injuries.
For Specific Government Functions
We may disclose PHI of military personnel and veterans to government benefits programs relating to eligibility and
enrollment, to Workers’ Compensation programs, to correctional facilities if you are an inmate, and for national
security reasons.
To Prevent Serious Threat to Health and Safety
If we come to believe that there is a serious threat to your safety or health or that of another person, or the public, we
can, and in many cases are required to, disclose some of your PHI. 

4. Uses and disclosures requiring you to have an opportunity to object
We can share some information about you with your family or close others. We will only share information with those
involved in your care and anyone else you choose such as close friends or clergy. We will ask you about who you want
us to tell what information about your condition or treatment. You can tell us what you want and we will honor your
wishes as long as it is not against the law.

5. An Accounting of Disclosures
When we disclose your PHI we keep some records of whom we sent it to, when we sent it, and what we sent. You can
get an accounting (a list) of many of these disclosures.

E. If You Have Questions or Problems
If you need more information or have questions about the privacy practices described above please speak to the
Privacy Officer whose name and telephone number are listed below. If you have a problem with how your PHI has
been handled or if you believe your privacy rights have been violated, contact the Privacy Officer. You have the right
to file a complaint with us and with the Secretary of the Federal Health and Human Services. We promise that we will
not in any way limit your care here or take any actions against you if  you complain.

Our Privacy Officer is: Mandi Mader, 301-681-3201, ext. 4

The effective date of this note is April 14, 2003.