Notice of Psychologist’s/Therapist’s Policies and Practices to Protect the Privacy of Your Health Information


I.  Uses and Disclosures for Treatment, Payment, and Health Care Operations  

Changes Psychological Services, PLLC (the “Practice”) may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written authorization.  To help clarify these terms, here are some definitions: 
• “PHI” refers to information in your health record that could identify you. 
• “Treatment, Payment and Health Care Operations”
– Treatment is when the Practice provides, coordinates or manages your health care and other services related to your health care.  An example of treatment would be when your psychologist/therapist consults with another health care provider, such as your family physician or another psychologist/therapist.
– Payment is when the Practice obtains reimbursement for your healthcare.  Examples of payment are when the Practice discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
– Health Care Operations are activities that relate to the performance and operation of the 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 the Practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of the Practice, such as releasing, transferring, or providing access to information about you to other parties.
• “Authorization” is your written permission to disclose confidential mental health information.  All authorizations to disclose must be on a specific legally required form.  

II.  Other Uses and Disclosures Requiring Authorization 

The Practice may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained.  In those instances when the Practice is asked for information for purposes outside of treatment, payment, or health care operations, the Practice will obtain an authorization from you before releasing this information.  The Practice will also need to obtain an authorization before releasing your Psychotherapy Notes, if applicable.  “Psychotherapy Notes” are notes your psychologist/therapist may make about your conversations during a private, group or joint counseling session, which will be kept separate from the rest of your 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) the Practice has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, since the law provides the insurer the right to contest the claim under the policy.

The Practice will also obtain an authorization from you before using or disclosing PHI in a way that is not described in this Notice.

III.  Uses and Disclosures without Authorization

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

• Child Abuse – If your psychologist/therapist knows or has reasonable cause to suspect that a child known to them in their professional capacity has been or is in immediate danger of being a mentally or physically abused or neglected child, they must immediately report such knowledge or suspicion to the appropriate authority.

• Adult and Domestic Abuse – If your psychologist/therapist believes that an adult is in need of protective services because of abuse or neglect by another person, they must immediately report this belief to the appropriate authorities.

• Health Oversight Activities – If a DC Licensing Board (Psychology, Social Work and/or Professional Counseling) is investigating your psychologist/therapist, the Practice may be required to disclose PHI to the Board.

• Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about the professional services provided to you and/or the records thereof, such information is privileged under DC law, and the Practice will not release information without the written authorization of you or your legally appointed representative or a court order.  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. 

• Serious Threat to Health or Safety – If your psychologist/therapist believes disclosure of PHI is necessary to protect you or another individual from a substantial risk of imminent and serious physical injury, they may disclose the PHI to the appropriate individuals. 

• Worker’s Compensation – If your psychologist/therapist is treating you for Worker’s Compensation purposes, they must provide periodic progress reports, treatment records, and bills upon request to you, the DC Office of Hearings and Adjudications, your employer, or your insurer, or their representatives.

• Other – Your psychologist/therapist and/or the Practice may use or disclose PHI without your authorization when the use and disclosure without your consent is allowed under other sections of Section 164.512 of the Privacy Rule and the District of Columbia’s confidentiality law.  This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as the U.S. Department of Health and Human Services or the District of Columbia Department of Health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions, such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

There may be additional disclosures of PHI that your psychologist/therapist and/or the Practice are required or permitted by law to make without your consent or authorization.  However, the disclosures listed above are the most common.

IV.  Patient’s Rights and Psychologist's/Therapist’s Duties

Patient’s Rights:
• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information.  However, the Practice is not required to agree to a restriction you request.

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.  (For example, you may not want a family member to know that you are seeing your psychologist/therapist.  On your request, the Practice will send your bills to another address.)  

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in the Practice’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.  The Practice may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  You may be denied access to Psychotherapy Notes if your psychologist/therapist believes that a limitation of access is necessary to protect you from a substantial risk of imminent psychological impairment or to protect you or another individual from a substantial risk of imminent and serious physical injury.  Your psychologist/therapist shall notify you or your representative if they do not grant complete access.  On your request, your psychologist/therapist will discuss with you the details of the request and denial process.   

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record.  The Practice may deny your request.  On your request, the Practice will discuss with you the details of the amendment process. 

• Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI.  On your request, the Practice will discuss with you the details of the accounting process. 

• Right to a Paper or Electronic Copy – You have the right to obtain a paper copy of the Notice from the Practice upon request, even if you have agreed to receive the Notice electronically.

• Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket – You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for your services.

• Right to be Notified if There is a Breach of Your Unsecured PHI – You have the right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) the Practice’s risk assessment fails to determine that there is a low probability that your PHI has been compromised.  

Psychologist’s/Therapist’s Duties:
• Your psychologist/therapist is required by law to maintain the privacy of PHI and to provide you with a Notice of their legal duties and privacy practices with respect to PHI.

• The Practice reserves the right to change the privacy policies and practices described in this Notice.  Unless the Practice notifies you of such changes, however, your psychologist/therapist is required to abide by the terms currently in effect. 

• If the Practice revises the privacy policies and procedures, your psychologist/therapist will provide you with a revised Notice either: (a) in person during the session that occurs subsequent to the revision being made; (b) or by mail at your designated mailing address.
V.  Questions and Complaints

If you have questions about this Notice, disagree with a decision the Practice and/or your psychologist/therapist makes about access to your records, or have other concerns about your privacy rights, you may contact Kirsten L. McNelis, Ph.D., Licensed Clinical Psychologist and Owner, Changes Psychological Services, PLLC at (202) 734-0535.

If you believe that your privacy rights have been violated and wish to file a complaint with your psychologist/therapist and/or the Practice, you may send your written complaint to Kirsten L. McNelis, Ph.D., Changes Psychological Services, PLLC 1627 K St. NW, Suite 500, Washington, DC 20006.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  The Practice will provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule.  Your psychologist/therapist and the Practice will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This Notice will go into effect on January 1, 2022.

The Practice reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that it maintains.  Again, the Practice will provide you with a revised Notice either: (a) in person during the session that occurs subsequent to the revision being made; (b) or by mail at your designated mailing address. 


By signing below, you acknowledge that you have received a copy of this Notice.  In addition, you acknowledge that you have had the opportunity to ask, and have answered, any questions regarding its content.  You also acknowledge that you understand your patient rights, your psychologist’s/therapist’s duties and the uses and disclosures of your information as explained above.    

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