Notice of Privacy Practices

Your health information rights

• Access and copies: Request to inspect or obtain an electronic or paper copy of records in the designated record set, subject to lawful exceptions. We generally respond within 30 days under HIPAA; shorter applicable Washington deadlines will be honored. A lawful, reasonable cost-based fee may apply.
• Corrections: Ask us in writing to amend information you believe is incorrect or incomplete. We may deny a request as permitted by law and will explain a denial in writing.
• Confidential communications: Request a reasonable alternative way or location for communications, such as a particular phone number, email address, or mailing address.
• Restrictions: Ask us to limit certain uses or disclosures. We are generally not required to agree, but when you pay in full out of pocket, you may require us not to disclose that service to a health plan for payment or health care operations, unless disclosure is required by law.
• Accounting: Request an accounting of certain disclosures made during the previous six years. One accounting in a 12-month period is generally free; lawful charges may apply to additional requests.
• Notice and representation: Obtain a paper copy of this Notice at any time. A verified legally authorized personal representative may exercise rights on your behalf, subject to applicable protections and limitations.
• Complaints: File a privacy complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate for making a complaint.

How we may use or disclose information

Treatment: We may use information to provide counseling and, as permitted by applicable law, coordinate care or consult with supervisors and other treating professionals. For example, we may consult with a clinical supervisor about treatment planning while protecting your privacy.

Payment: We may use information to collect session fees, process authorized card payments through Square, and prepare a superbill at your request. For example, payment processing may include identifying information and the amount due. We do not routinely submit insurance claims.

Health care operations: We may use information for practice administration, quality improvement, compliance, professional supervision, and secure management of paper records. We use Square for payment processing, Google Calendar for appointment scheduling, and Zoom for telehealth appointments. These services may process limited information necessary for their functions; we do not use them as an electronic clinical recordkeeping system. Where a vendor acts as our HIPAA business associate, we require an applicable business associate agreement and appropriate safeguards.

Other legally permitted or required situations: Subject to Washington and federal limits, disclosures may occur for mandatory reports of suspected abuse or neglect, serious threats to health or safety, public health activities, health oversight, certain law enforcement or governmental requests, workers’ compensation, qualifying research, medical examiners or coroners, and valid judicial or administrative processes. A subpoena alone does not necessarily authorize release of confidential mental health records; we evaluate the applicable legal requirements before disclosure.

We may contact you about appointments and practice communications using the contact methods you provide, subject to your confidential communication requests. Google Calendar is used for scheduling and Zoom for virtual sessions. Counseling records and signed forms are kept in locked paper files rather than uploaded to an electronic health record. Ordinary email and text can carry privacy risks; avoid sending sensitive clinical details through unsecured channels.

Special protections for Washington mental health records

Under RCW 70.02, the fact that you receive mental health services and information obtained or maintained during those services receive specific confidentiality protections. We will not disclose mental health treatment records without your valid authorization unless a particular state or federal legal exception permits or requires disclosure. Some treatment and care coordination disclosures are permitted under RCW 70.02.230 with safeguards. Separate psychotherapy notes, if maintained, have additional restrictions and generally require specific authorization for release, subject to narrow legal exceptions.

In couples counseling, both participants may have privacy and record access rights. We address individual communications, joint treatment records, and releases under applicable law and the informed consent terms; this Notice does not create an automatic right for one partner to access another person’s separately protected records.

Your choices and uses requiring authorization

Where legally permitted, you may tell us whether to share relevant information with family, friends, or others involved in your care, or for disaster relief. We will respect your stated preferences to the extent required by law. Most disclosures of psychotherapy notes, uses for marketing, and sales of PHI require your written authorization, with applicable exceptions. We do not sell your PHI or use it for marketing without required authorization. Other uses or disclosures not described here will occur only with your written authorization or as allowed or required by law. You may revoke an authorization in writing; revocation does not undo actions already lawfully taken in reliance on it.

Substance use disorder records protected by 42 CFR Part 2

Some substance use disorder (SUD) treatment records may be protected by federal law, 42 CFR Part 2, in addition to HIPAA and Washington law. If we receive or maintain records subject to Part 2, we will apply its restrictions. Subject to a valid Part 2 consent and applicable rules, such records may be used or disclosed for treatment, payment, and health care operations. Part 2 records generally cannot be used or disclosed in civil, criminal, administrative, or legislative proceedings against you without your specific written consent or a qualifying court order and accompanying legal process, as applicable. Part 2 records are not automatically subject to the same disclosure rules as other health information. Any fundraising communications using Part 2 records, if ever undertaken, would require advance clear notice and an opportunity to opt out; this practice does not currently conduct such fundraising.

Our privacy responsibilities

As a HIPAA covered entity, we are required by law to maintain the privacy of your PHI, provide this Notice of our legal duties and privacy practices, follow the terms of the Notice currently in effect, and notify affected individuals following breaches of unsecured PHI when required by law. We maintain paper counseling records and copies of completed, signed forms in locked storage at a confidential, secure location, with access restricted to authorized persons. We also apply appropriate safeguards to the limited electronic information used for payments, scheduling, telehealth, and communications. We will make a good faith effort to obtain acknowledgment that you received this Notice; declining to sign does not affect your right to treatment. We may revise this Notice and apply revised terms to information we already hold as permitted by law. We will make the current Notice available on request, at our office, and prominently on any practice website that provides information about our services.

Washington notice of information practices

We keep a record of the health care services we provide you. You may ask to see and copy that record and request corrections. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or requires disclosure. Contact Revival Restoration, LLC using the details above to inspect records or learn more. This statement is intended to supplement the notice requirements of RCW 70.02.120.

Privacy questions, requests, and complaints

Privacy contact: Karolina Kovalev, MA, LMHCA, Revival Restoration, LLC. Send written privacy requests or complaints to appointments@kccnw.org or to the practice mailing address above. Telephone: 971 464 1155. Do not include sensitive clinical information in ordinary email unless you accept the associated risk; request a secure method when needed.

You may also complain to the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue SW, Washington, DC 20201; 1-877-696-6775; www.hhs.gov/hipaa/filing-a-complaint. For Washington professional licensing concerns, contact the Washington State Department of Health at 360-236-4700.