Privacy Policy






Your provider is required by law to maintain the privacy of your protected health information (PHI) and to provide you with notice of your privacy rights and my legal duties and privacy practices with respect to your PHI. He/she is required to abide by the terms of this notice with respect to your PHI but reserve the right to change the terms of this notice and make the new notice provisions effective for all PHI that we maintain.


Each time you visit a hospital, physician, mental health professional or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and in the case of a mental health professional, can include psychotherapy notes. This information, often referred to as your health or medical record, serves as a:

  • Basis for planning your care and treatment.
  • Means of communication among the many health professionals who contribute to your care.
  • Legal document describing the care you received.
  • Means by which you or a third-party payer can verify that services billed were actually provided.
  • A tool in educating health professionals.
  • A source of data for medical research.
  • A source of information for public health officials charged with improving the health of the nation.
  • A source of data for facility planning and marketing.
  • A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to:

  • Ensure its accuracy.
  • Better understand who, what, when, where, and why others may access your health information.
  • Make more informed decisions when authorizing disclosure to others.


Although your health record is the physical property of the provider that compiled it, the information belongs to you. You have the following privacy rights:

  1. The right to request restrictions on the use and disclosure of your PHI to carry out treatment, payment or health care operations. You should note that your provider is not required to agree to be bound by any restrictions that you request but is bound by each restriction that is agreed to.
  2. To receive confidential communication of your PHI unless your provider determines that such disclosure would be harmful to you.
  3. To inspect and copy your PHI unless, in your provider’s professional judgment, the access requested is reasonably likely to be harmful to you or endanger your life or physical safety or that of another person.
  4. To amend your PHI upon your written request to your provider setting forth your reasons for the requested amendment. Your provider has the right to deny the request if the information is complete or has been created by another entity.
    Your provider is required to act on your request to amend your PHI within sixty (60) days but this deadline may be extended for another thirty (30) days upon written notice to you. If your requested amendment is denied, you will be provided with written notice of the decision and the basis for it. You will then have the right to submit a written statement disagreeing with the decision which will be maintained with your PHI. If you do not wish to submit a statement of disagreement you may request that your provider include your request for amendment and our denial with any future disclosures of your PHI.
  5. Upon request to receive an accounting of disclosures of your PHI made within the past 6 years of your request for an accounting. Disclosures that are exempted from the accounting requirement include the following:
    • Disclosures necessary to carry out treatment, payment and health care operations.
    • Disclosures made to you upon request.
    • Disclosures made pursuant to your authorization.
    • Disclosures made for national security or intelligence purposes.
    • Permitted disclosures to correctional institutions or law enforcement officials.
    • Disclosures that are part of a limited data set used for research, public health or health care operations.
      Your provider is required to act on your request for an accounting within sixty (60) days but this headline may be extended for another thirty (30) days upon written notice to you of the reason for the delay and the date by which the accounting will be provided. You are entitled to one (1) accounting in any twelve (12) month period free of charge.
  6. To receive a paper copy of this privacy notice.
  7. The right to complain to your provider and to the Secretary of the U.S. Department of Health and Human Services (HHS) if you believe your privacy rights have been violated. You may submit your complaint to this office in writing setting out the alleged violation. Your provider is prohibited by law from retaliating against you in any way for filing a complaint.



Your written authorization is required before your provider can use or disclose psychotherapy notes, which are defined as notes documenting or analyzing the contents of your conversations during counseling sessions and that are separated from the rest of your clinical file.
Psychotherapy notes do not include medication prescription and monitoring, session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date.

It is our policy to protect the confidentiality of your PHI to the best of our ability and to the extent permitted by law. There are times however, when use or disclosure of your PHI including psychotherapy notes, is permitted or mandated by law even without your authorization.

Situations where your provider is not required to obtain your consent or authorization for use or disclosure of your PHI include the following circumstances:

  • By your provider or office staff for treatment, payment or health care operations as they relate to you.

    For example: Information obtained by your provider will be recorded in your record and used to determine the course of treatment that should work best for you. Your provider will document in your record your work together and when appropriate he/she will provide a subsequent counselor or health care provider with copies of various reports that should assist him or her in treating you once your current therapeutic relationship is terminated.

    For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. (Your PHI may also be provided to business associates, such as billing companies, claims processing companies, and others that process health care claims for your provider.)
    For example: Quality control – Your provider might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. He/she may also provide your PHI to attorneys, accountants, consultants, or others to make sure that he/she is in compliance with applicable laws.

  • To avoid harm. For example, your provider may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public.
  • When compelled or permitted by the fact that you are in such mental condition as to be dangerous to yourself or the person or property of others, and if your provider determines that disclosure is necessary to prevent the threatened danger.
  • When mandated by Child Abuse and Neglect Reporting laws. For example, if your provider has a reasonable suspicion of child abuse or neglect.
  • When mandated by Elder/Dependent Adult Abuse Reporting laws. For example, if your provider has a reasonable suspicion of elder abuse or dependent adult abuse.
  • When compelled or permitted by the fact that you tell your provider of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.
  • In the event of an emergency to any treatment provider who provides emergency treatment to you.
  • To defend a legal action or other proceeding brought by you against your provider.
  • When required by the Secretary of the Department of Health and Human Services in an investigation to determine compliance with the privacy rules.
  • In the course of any judicial or administrative proceeding in response to:
    • An order of a court or administrative tribunal so long as only the PHI expressly authorized by such order is disclosed, or
    • A subpoena, discovery request or other lawful process, that is not accompanied by an order of a court or administrative tribunal so long as reasonable efforts are made to give you notice that your PHI has been requested or reasonable efforts are made to secure a qualified protective order, by the person requesting the PHI.

      For example: Child custody cases and other legal proceedings in which your mental health or condition is an issue are the kinds of suits in which your PHI may be requested.

  • In connection with a lawsuit or other action to collect fees for services.
  • In compliance with a court order or court ordered warrant, or a subpoena or summons issued by a judicial officer, a grand jury subpoena or summons, a civil or an authorized investigative demand or similar process authorized by law provided that the information sought is relevant and material to a legitimate law enforcement inquiry, the request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought and de-identified information could not be reasonably used.
  • To a health oversight agency for oversight activities authorized by law as they may relate to us (i.e., audits; civil, criminal or administrative investigations, inspections, licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions).
  • To a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law.
  • To funeral directors consistent with applicable law as necessary to carry out their duties with respect to the decedent.
  • To the extent authorized by and the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
  • To a public health authority that is authorized by law to collect or receive such information for the purposes of preventing or controlling a disease, injury or disability, including, but not limited to, the reporting of disease, injury, vital events such as birth, death, and the conduct of public surveillance, public health investigations, and public health interventions.
  • To a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition, if the covered entity or public health authority is authorized by law to notify such persons as necessary in the conduct of a public health intervention or investigation.
  • To a law enforcement official if your provider believes in good faith that the PHI constitutes evidence of criminal conduct that occurs on the premises.
  • Using professional judgment, to a family member, other relative or close personal friend or any other person you identify, your provider may disclose PHI that is relevant to that person’s involvement in your care or payment related to your care.
  • To authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities authorized by the National Security Act and implementing authority.
  • To Business Associates under a written agreement requiring Business Associates to protect the information. Business Associates are entities that assist with or conduct activities on your provider’s behalf including individuals or organizations that provide legal, accounting, administrative, billing and similar functions.

Your provider or office staff may contact you with appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.

If you have any questions or would like additional information you should bring this to your provider’s attention at the first opportunity. Questions or requests may be directed to your provider at: 2233 North Hamline Ave Roseville, MN 55113 Telephone 651 447 3755 Fax 651-444-8923