Teletherapy Notice of Privacy Practices



Your health record contains personal information about you and your health. This information, which may identify you and that relates to your past, present or future physical or mental health or condition and related health care services, is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law and the Ethical Principles of Psychologists and Code of Conduct (referred to hereafter as “APA Ethics Code.”) It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request.


For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with other clinicians or other treatment team members. We may disclose PHI to any other consultant only with your authorization.
For Payment: We may use and/or disclose your PHI so that we can receive payment for the treatment services provided to you, as applicable. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for the purposes of collection.

For Healthcare Operations: We may use or disclose, as needed, your PHI in order to support business activities, including but not limited to, quality assessment activities, case management, employee review activities, licensing and conducting or arranging other business-related
activities. For training or teaching purposes, PHI will be disclosed only with your authorization.

Your Authorization: Under the law, we must make disclosures of your PHI to you upon your request. You may give written authorization to use your health information or to disclose it to anyone for any purpose. If you give an authorization, you may revoke it in writing at any time. Your revocation will not affect any use of disclosures permitted by your authorization while it is in effect. Unless you give a written authorization, we cannot use or disclose your PHI for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your PHI to you. We may disclose your PHI to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for healthcare, but only with your authorization. In the case of family members who are paying for your services, we will obtain a limited release of information allowing us to contact those individuals in order to collect payment.

Verbal Permission: We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission; this verbal permission will be documented in writing as soon as feasible.

Persons Involved in Care: We may use or disclose PHI to notify or assist in the notification of (including identifying or locating a family member, your personal representative or another person responsible for your care) of your location, general condition, or death. If you are present, then prior to disclosure of your PHI, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using professional judgment, disclosing only PHI that is directly relevant to the person’s involvement in your healthcare.

Required by Law: We may use or disclose your health information when we are required to do so by law. These situations include abuse or neglect of a child or vulnerable adult, threats of harm to others whether by you or a person known to you, matters of national security, and direct threats of harm to yourself.

Abuse or Neglect: We may disclose your PHI to appropriate authorities without your consent if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes, as required by law. We may only do so against your will if you are under the age of 18 or are legally considered a vulnerable adult. We may disclose your PHI to the extent necessary to avert a serious threat to your health or safety or the safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligences, and other national security activities. We may disclose to correctional institutions or law enforcement officials having custody of PHI of an inmate or client under certain circumstances.

Without Authorization: Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of circumstances. The types of uses and/or disclosures that may be made without your authorization are those that are:

1. Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the Psychology Licensing Board or the health department)
2. Required by Court Order
3. Necessary to prevent or lessen a serious and imminent threat to the health and/or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.


You have the following rights regarding the PHI we maintain about you. To exercise any of these rights, please submit your request in writing:

Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies. If access is denied, you or your personal representative will be provided with a written denial, setting forth the basis for the denial, a description of how you may appeal the decision and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services.

Right to Amend: If you feel that the PHI we have about you in incorrect or incomplete, you may ask me to amend the information, although we are not required to agree to the amendment.

Right to an Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your health information for purposes other than treatment, payment, health operations and certain other activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment or health care operations. We are not required to agree to your request.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Right to copy of this notice: You have the right to a copy of this notice.


Generally speaking, the information provided by and to the client (you) during therapy sessions is legally confidential and cannot be released without the client’s consent. There are exceptions to this confidentiality, some of which are listed in section 12-43-218 of the Colorado Revised Statutes and the HIPAA Notice of Privacy Rights you were provided, as well as other exceptions in Colorado and Federal law. For example, mental health professionals are required to report suspected child abuse to authorities. If a legal exception arises during therapy, if feasible, you will be informed accordingly. The Mental Health Practice Act (CRS 12-43-101, et seq.) is available at the Colorado Department of Regulatory Agencies (DORA)

If you are concerned that we have violated your privacy rights, or you disagree with a decision about access to your health information, or in response to a request you made to amend or restrict the use of disclosure of your PHI, you may contact us at the address listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. We can provide you with the appropriate address upon request.


We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice.

If you wish to inspect your records, receive a listing of disclosures, or correct or add to the information in your record, or if you have any questions, complaints or concerns, please contact:

Tri County Health Network PO Box 4178
Telluride, CO 81435 Phone: 970.708.7096

    The effective date of this notice is February 1, 2017. Your signature below indicates that you agree to abide by its terms during our professional relationship. I acknowledge receiving and reading a complete copy of this Notice of Privacy Practices. I have read the preceding information, and I understand my rights or my child’s rights as the responsible party. I further acknowledge that, as of today’s date, I have no questions regarding the Notice of Privacy Practices

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