NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

Make sure that protected health information (“PHI”) that identifies you is kept private.
Give you this notice of my legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.
I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For my use in treating you.
b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.

Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.
Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on May 15, 2020

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

Disclosure and Consent From

Qualifications

Doctor of Psychology (PsyD), California Southern University, 2018

Masters in Social Work (MSW), University of Vermont, 2011

Licensed Clinical Psychologist - California #32052

Licensed Independent Clinical Social Worker (LICSW) - Washington # LW60906496

Licensed Clinical Social Worker (LCSW) - Montana #11384

Eye Movement Desensitization and Reprocessing (EMDR) Practitioner

Somatic Experiencing® Practitioner

Somatic Experiencing® - Assistant Trainer

Yoga Instructor, Certified 500hr

Therapeutic Approach

I offer a relational, client centered approach guided by an understanding of your innate capacities and the role society plays in life challenges. The practice is eclectic in nature as I draw upon narrative, cognitive-behavioral, and dialectical behavioral approaches while implementing EMDR, Somatic Experiencing®, yoga, meditation, breathwork, and expressive therapies.

I am experienced in supporting children, adolescents, adults, and families in negotiating challenges associated with; adoption, sexual/physical abuse, addiction, grief, suicidality, anger, anxiety, depression, self-esteem, autism, inattention, and impulsivity.

Benefits and Risks of Therapy

Therapy offers the space to explore your past and present experiences as well as hopes for the future. As you begin this therapeutic exploration of self, there is a risk for strong uncomfortable emotions, sensations, and memories to arise. Realizations made can initiate new ways of perceiving family members, partners, or friends. Therapy requires effort on your part and it is important that you are engaging willingly in treatment.

Most people benefit from therapy through increased coping skills, abilities to tolerate distress, the relief of symptoms relating to trauma, depression and anxiety as well as self-growth and understanding. I am happy to suggest literature specific to the approaches offered to support these claims.

Professional Records

I am required to maintain records of the services provided. Two sets of records may be kept. The first is your clinical record and includes information about the reasons for seeking therapy, a description of how your problem impacts on your life, diagnosis, goals set for treatment, progress towards those goals, medical and social history, treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, billing records, and any reports that have been sent to anyone.

The second set of records kept includes psychotherapy notes. These notes are designed to assist in providing you with the best treatment. The contents of psychotherapy notes can include the contents of our conversations, my analysis of this information, and their relationship to your therapeutic goals. They may also contain sensitive information that you reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. Insurance companies may request your clinical records but they cannot receive a copy of psychotherapy notes without your signed authorization. Insurance companies cannot require your authorizations as a condition of coverage.

You may examine and/or receive a copy of your medical notes. This request must be in writing and, if you request a physical copy of the information, you may be charged a fee for copying costs. I may deny this request if I determine that their release would be harmful to your physical, mental or emotional state. All records are kept in a secure electronic medical records database.

Confidentiality and Reporting

You have the right to confidentiality regarding your identity, participation in therapy, the content of discussions and the documentation. Exceptions to confidentiality do exist as I am required to break confidentiality and make reports to relevant authorities if:

a. There is reason to suspect or you report an incident of abuse or neglect towards a child, dependent adult or elder adult.

b. There is reason to suspect that you are in danger to yourself. In most cases, I will be required to contact a hospital, your family, and/or a crisis team in the area.

c. There is reason to suspect you are unable to care for yourself due to a severe mental disability. In most cases, I will be required to contact a hospital, your family or a crisis team in the area.

d. There is reason to believe that you will cause serious harm towards one or more persons.

e. I am court ordered to share certain confidential information.

f. You use health insurance to pay for our sessions. In most cases, I will be required to provide a diagnosis, treatment goals, and brief progress notes to ensure payment.

g. You are a member of the military and they are asked to provide information for purpose of a lawful conduct investigation or when assessing your fit for a particular service.

h. You are entering therapy through an EAP program. In most cases, I will be require to provide information about your attendance and compliance to your employer.

i. If a serious threat of physical violence is made towards me, I will be required to notify local law enforcement.

j. You provide me with written permission to speak with an insurance company or third party.

In the event confidential information needs to be shared only pertinent information will be disclosed with specific relevant authorities.

Minors

If you are a minor under the age of 13, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

Grievances

You have a right to choose who you seek support from, the right to receive second opinions, and to refuse and terminate therapy at any time. If you have any concerns regarding the support offered, I hope that you will bring them directly to me for consideration (lori@drlorimariani.com). If you are dissatisfied with the response to your request, you may notify the Department of Health at 360-753-1767 in Washington or the Montana Bureau of Behavioral Health (406) 444-6880 if in Montana.

Multiple Relationships

Once beginning a therapeutic relationship, it is unethical to have any other type of relationship with your counselor including socializing as peers. In addition, it is unethical for a counselor and client to interact in a sexual or romantic manner during or after supportive treatment. In addition, it is possible that you will see me outside of appointed times while in the community. In this case, I will ignore you to protect your right to confidentiality.

Fees: The fee for service is $200 for a 55-minute session. Fees are due at the time of service. I am an out of network provider. I will provide you with an superbill to submit to your insurance for reimbursement. I offer consideration for the first missed appointment due to illness and unforeseen circumstances. However, it is expected that you notify me of cancellations or rescheduling 24 hours in advance. If an appointment is missed or you contact me to reschedule less than 24 hours before the appointment time, you will be expected to pay a $100 fee.**

If there are any fees remaining unpaid after a reasonable effort to obtain payment, payment may be sought with the use of a collection agency. You will be notified 30 days prior to me taking this action.

Prorated services include: The first 15 minutes of services including: telephone calls, emails, consults, requested reports, consultations with other professionals, and paperwork preparation are at no cost to you. Any time spent in excess of 15 minutes will incur a prorated based on your session fee (30 minutes spent = $100 fee)

Telehealth: includes the practice of health care delivery, assessment, diagnosis, consultation, treatment, transfer of medical data, and psychoeducation using interactive audio, video, or data communications. You will need to have a broadband internet connection or a smart phone device with a good cellular connection at home or at the location deemed appropriate for services. In case of technology failure, you may contact me via phone to coordinate alternative methods of treatment. All existing laws regarding your access to medical information and copies of your medical records apply to telehealth. All patient-identifiable images or information from this telehealth interaction will remain private.

Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth. All existing confidentiality protections under federal and Washington State law apply to information disclosed during telehealth.

Electronic Communication: Security cannot be guaranteed in electronic forms of communication. When communicating via email, please be mindful of this when sharing personal health information. By signing below, you authorize Dr. Lori Mariani to communicate with you via electronic means including for appointment reminders, scheduling, treatment coordination. You also authorize, Dr. Lori Mariani to respond to your communications through electronic means and provide electronic copies of documents, including billing statements, superbills, and treatment records.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

Contacting Me

I am not available to respond to communication if in session, during evenings, or on Friday and Saturday. You may send a message to me at: Lori@DrLoriMariani.com and I will typically respond within 48 hours. I request that you do not use this method of communication to discuss therapeutic content and/or request assistance for emergencies. Please know that email does not offer a completely secure form of confidential communication.

In the event of a crisis or emergency, please call 911 or contact the local crisis line at (1-866-4-CRISIS (1-866-427-4747) or 206-461-3222). I am not available for immediate assistance in emergency situations.

Lori@DrLoriMariani.com

Disclaimer:

The content on this site is meant for informational purposes only. This site content does not replace professional medical or psychiatric support and advice.