Privacy and Confidentiality



(This and the following page are to be separated from the application and given to the client or the guardians of the client for their own records.)


We are providing you with this notice:

We are required by a federal law known as the Health Insurance Portability and Accountability Act (HIPAA) to give you this Notice.  This notice will tell you about the ways in which we may disclose health information about you and will describe your rights and our obligations regarding the use and disclosure of that information.

Your Health Information

This notice applies to the information and records we have about your health, health status, and the health care services you receive from Jeff Gregson Therapy,  this information and records relates primarily to counseling services you have received from us.

How We May Use and Disclose Health Information about You

For Treatment

We may use and disclose health information about you so that we can be paid by you, another party, including current or future bishops if they are paying any portion of the fee for the services we provide to you.  

For Agency Operations

We may use and disclose health information about you in order to run our office and make

Sure that you and our other clients receive quality care. For example, we may use your health information to evaluate the performance of our staff or to contact you to remind you of your appointments.

Please notify us in writing if you do not want us to contact you to remind you of your appointments.

Special Situations

We may use or disclose your health information without your permission for several reasons.  These reasons include:

•       Disclosing your health information when we believe that disclosure is necessary to prevent a serious threat to your health and safety or the health and safety of another person.

•       Disclosing your health information as required by federal, state or local law

•       Disclosing your health information as required by law to prevent injury or suspected abuse or neglect.

Disclosing your health information is response to a court order, subpoena, warrant, summons or similar proce


Other Uses and Disclosures of Health Information

Except where otherwise required or authorized by law, we will not use or disclose your health information for any purpose without your written authorization.  If you authorize us to use or disclose health information about you, you may revoke your authorization, in writing at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization, but we cannot take back any uses disclosures we have already made with your permission.

Your Rights Regarding Your Health Information

You have the following rights with regard to your health information:

•       You may inspect or copy your health information, with certain exception.

•       If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information

•       You may obtain an accounting of our disclosures of your health information. This is a list of all of our disclosures of your health information for purposes other than treatment, payment and health care operations.

•       You have the right to request that we restrict or limit our use or disclosure of your health information to only treatment, payment o health care operations. We are not required to comply with your request.

•       You may request that we communicate with you about your health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work.

•       You have the right to receive paper copy of this notice.

If you want to exercise any of these rights, please contact the agency director, in writing, at the office where you are receiving counseling.

Changes to This Notice

We have the right to change this notice. If we do so, the new notice will apply to the health information we may already have about you and to the health information that we receive in the future.  We are required to abide by the most current notice that is in effect. We will post a summary of the most current information in our office. You are entitled to receive a copy of the most current notice.


If you believe your privacy has been violated, you may file a complaint with our office or with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.

This notice if effective as of April 1, 2003