Your rights and my policies as required

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Our legal duty to you:


I and my colleagues at Queen City Counseling & Consulting are required by law to protect the privacy of your “protected health information” (PHI), which can be identified with you.  We also have legal and professional duties to you as your therapists. But sometimes PHI may or must be released. This notice explains your rights and ours.


What to expect:

The purpose of meeting with a counselor or therapist is to get help with problems in your life that are bothering you or that are keeping you from being successful in important areas of your life. You may be here because you wanted to talk to a counselor or therapist about these problems. Or, you may be here because your parent, guardian, doctor or teacher had concerns about you. When we meet, we will discuss these problems. I will ask questions, listen to you and suggest a plan for improving these problems. It is important that you feel comfortable talking to me about the issues that are bothering you. Sometimes these issues will include things you don’t want your parents or guardians to know about. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor or therapist. Privacy, also called confidentiality, is an important and necessary part of good counseling.

As a general rule, I will keep the information you share with me in our sessions confidential, unless I have your written consent to disclose certain information. There are, however, important exceptions to this rule that are important for you to understand before you share personal information with me in a therapy session. In some situations, I am required by law or by the guidelines of my profession to disclose information whether I have your permission. In other situations, I am permitted by law and my profession to disclose information without your permission.  I have listed some of these situations below.

Confidentiality will not be maintained when:

    • Safety Concerns for Yourself: You tell me you plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian of what you have told me and how serious I believe this threat to be. I must make sure that you are protected from harming yourself.
    • Safety Concerns for Others:  You tell me you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future. In this situation, I will inform your parent or guardian, and I will inform the person who you intend to harm.  
  • High Risk Situations: You are doing things that could cause serious physical, emotional, or legal harm to you or someone else, even if you do not intend to harm yourself or another person. In these situations, I will need to use my professional judgment to decide whether to alert a parent or guardian.
  • Abuse and/or Neglect: You tell me you are being abused-physically, sexually or emotionally-or that you have been abused in the past. In this situation, I am required by law to report the abuse to the Department of Social Services.
  • Court Mandate/Subpoenas: You are involved in a court case or a law enforcement matter, and a legal demand (such as a subpoena or a search warrant) is made for information about your counseling or therapy. If this happens, I will not disclose information without your written agreement unless the court requires me to. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you before I do so.

Communicating with your parent(s) or guardian(s):

Except for situations such as those mentioned above, I will not tell your parent or guardian specific things you share with me in our private therapy sessions. This includes activities and behavior that your parent/guardian would not approve of — or would be upset by — but that do not put you at risk of serious and immediate harm. However, if your risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether you are in serious and immediate danger of being harmed. If I feel that you are in such danger, I will communicate this information to your parent or guardian.

Even if I have agreed to keep information confidential – to not tell your parent or guardian – I may believe that it is important for them to know what is going on in your life. In these situations, I will encourage you to tell your parent/guardian and will help you find the best way to tell them. Also, when meeting with your parents, I may sometimes describe problems in general terms, without using specifics, in order to help them know how to be more helpful to you.

Communicating with other primary adults in your life:

School: I will not share any information with your school unless I have your permission and permission from your parent or guardian. Sometimes I may request to speak to someone at your school to find out how things are going for you. Also, it may be helpful in some situations for me to give suggestions to your teacher or counselor at school. If I want to contact your school, or if someone at your school wants to contact me, I will discuss it with you and ask for your written permission. A very unlikely situation might come up in which I do not have your permission but both I and your parent or guardian believe that it is very important for me to be able to share certain information with someone at your school. In this situation, I will use my professional judgment to decide whether to share any information.

Doctors: Sometimes your doctor and I may need to work together; for example, if you need to take medication in addition to seeing a counselor or therapist. I will get your written permission and permission from your parent/guardian in advance to share information with your doctor. The only time I will share information with your doctor even if I don’t have your permission is if you are doing something that puts you at risk for serious and immediate physical/medical harm.

Other instance in which your PHI may be shared:

  • For your health care treatment.  We may use and disclose PHI to provide treatment or help you obtain treatment for other providers.
  • Examples: Within the practice we may discuss with other Queen City clinicians to gain alternative perspectives in treatment that may be beneficial for your care. If we feel it is  important to share your information with others outside of the practice we will obtain your written permission through a release of information prior to doing so.
    • For our health care operations:  We may disclose your Protected Health Information (“PHI”) to facilitate the efficient and correct operation of my practice with your prior consent.

  • Examples: Quality control – We may 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. We may also provide your PHI to my attorneys, accountants, consultants, and others to make sure that we are in compliance with applicable laws.

We will not reveal more information than we need to, and these people are also required to keep your PHI confidential.

    • To obtain payment for your treatment:  In the event that we start taking insurance we may use and disclose your PHI to bill and collect payment for the treatment and services provided

  • Example: We may send your PHI to your insurance company or health plan in order for you to get payment for the health care services that were provided to you. We could also provide your PHI to business associates, such as billing companies, claims processing companies, accounting services, and others that process health care claims for my office.
  • If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law.
  • Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess my compliance with HIPAA regulations.
      • Patient incapacitation or emergency: We may also disclose your PHI to others without your consent if you are incapacitated or if an emergency exists.

    • Examples: Your consent is not required if you need emergency treatment provided that we attempt to get your consent after treatment is rendered. In the event that we try to get your consent, but you are unable to communicate (i.e., if you are unconscious or in severe pain) but we think that you would consent to such treatment if you could, we may disclose your PHI. Parents will also be contacted immediately in the above-mentioned event.


    What rights you have regarding your PHI:

    • Signed consent for release of information: In any other situation we will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (assuming that we have not taken any action subsequent to the original authorization) of your PHI.
    • The right to see and get copies of your PHI:  In general, you have the right to see your PHI that is in our possession, or to get copies of it; however, you must request it in writing sent Queen City Counseling & Consulting, PLLC attention: __________________________________________. If we do not have your PHI, but we know who does, we will advise you how you can get it. You will receive a response from us within 30 days of receiving your written request. Under certain circumstances, we may feel that we must deny your request, but if we do, we will give you, in writing, the reasons for the denial. We will also explain your right to have the denial reviewed. If you ask for copies of your PHI, we will charge you not more than $0.25 per page. We may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.
    • The right to request limits on uses and disclosures of your PHI: You have the right to ask that we limit how we use and disclose your PHI. While we will consider your request, we are not legally bound to agree. If we do agree to your request, we will put those limits in writing and abide by them except in emergency situations. We do not have the right to limit the uses and disclosures that we are legally required or permitted to make.
    • The right to choose how we send your PHI to you: It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). We are obliged to agree to your request providing that we can give you the PHI in the format you requested without undue inconvenience.
    • The right to get a list of the consented disclosures: You are entitled to a list of consented disclosures of your PHI that we have and have made. This list will not include disclosures made for national security purposes, to corrections or law enforcement personnel.

    • We will provide the list to you at no cost, unless you make more than one request in the same year, in which case we will charge you a reasonable sum based on a set fee for each additional request.
    • The right to get this notice by email. You have the right to get this notice by email. You have the right to request a paper copy as well. An updated copy will always be posted on our website.
    • Psychotherapy notes.  One part of your PHI is different than the rest.  Like many therapists, I make working notes during or shortly after sessions.  Some people call these process notes, and others call them psychotherapy notes, and they contain my initial thoughts, impressions, and questions, which I may later decide are incorrect.  As these notes are merely interpretations, impressions, and reminders on areas of treatment to consider and not always concrete facts they will not be shared as they may not be helpful for you in your treatment and recovery process.  In addition, I will not share them with others unless the law requires it or it is necessary for treatment, payment, or operations, and the law permits it.  


    How to make a complaint if you feel your privacy rights have been violated:

    If, in your opinion, we may have violated your privacy rights, or if you object to a decision that was made about access to your PHI, you are entitled to file a written complaint with the Department of Health and Human Services at the address listed below or call them at 1-800-368-1019.  


    Secretary of the Department of Health and Human Services

    200 Independence Avenue SW

    Washington, DC  20201


    You may also contact Amy Gregor, LCSW or Ashley McGurkin, LCSW at Queen City Counseling & Consulting, PLLC. Our updated contact information will be listed at

    If you file a complaint about our privacy practices, we will take no retaliatory action against you.