THE REAL WORK, 4790 SW Watson Ave, Beaverton OR 97005, 

503-905-9735

HIPAA 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 understand that your health care is personal, and I am committed to protecting health information about you. During our work together, I will create a record of the care and services you receive from me and need this record to provide you with quality care, as well as 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, as well as describe your rights to the health information I keep about you. Additionally, this notice describes certain obligations I have regarding the use and disclosure of your health information. 

Your Rights

You have several rights regarding your Protected Health Information (PHI):

1. Right to Inspect and Copy
   You may request access to your health records to inspect and obtain a copy of your PHI. Requests must be submitted in writing. In some cases, I may deny your request, but you have the right to request a review of the denial by a licensed healthcare professional not involved in the original decision.

• Fees: A reasonable fee may be charged for copying, mailing, or preparing records.

2. Right to Request Amendments
   If you believe that your health information is incorrect or incomplete, you may request an amendment. Your request must be in writing and include a reason for the requested amendment.

• If I deny your request, you have the right to submit a written statement of disagreement, which will be included in your record.

3. Right to an Accounting of Disclosures
   You may request a list of certain disclosures of your PHI made in the past six years, excluding those related to treatment, payment, or healthcare operations.

• This list will include the date of disclosure, the recipient, the purpose, and a description of the information disclosed.

4. Right to Request Restrictions
   You can request restrictions on how your information is used or shared. While I am not required to agree to all restrictions, I will make reasonable efforts to comply unless restricted by law or necessary for emergency care.

• Example: You may request that I do not share information with a specific family member or insurance company.

5. Right to Confidential Communications
   You can request that I communicate with you in a specific way or at a certain location. For instance, you may ask me to contact you only via email or send mail to a P.O. box instead of your home address.

6. Right to a Paper Copy of This Notice
   You may request a paper copy of this notice at any time, even if you have received it electronically.

7. Right to File a Complaint
   If you feel your privacy rights have been violated, you can file a complaint with me or with the U.S. Department of Health and Human Services (HHS). Filing a complaint will not affect your care.

Your Choices

In some situations, you have the right to request or deny the sharing of your information. These include:

• Sharing with family, friends, or caregivers: I will only share your information with those you designate or in cases where it is necessary for your care and you have given verbal or written permission.

• Marketing communications: Your information will not be used for marketing purposes without your explicit written consent.

• Fundraising communications: If applicable, you have the right to opt out of receiving any fundraising communications related to this practice.

My Responsibilities

I am legally required to:

• Maintain the privacy and security of your PHI.

• Notify you promptly if a breach occurs that compromises the privacy or security of your information.

• Provide you with this Notice of Privacy Practices and follow its terms.

• Not use or share your information other than as described in this notice unless you give written authorization.

Uses and Disclosures of Your Health Information

Below are examples of how your PHI may be used and disclosed.

Uses and Disclosures for Treatment, Payment, and Healthcare Operations (No Authorization Required):

1. For Treatment:
   Your information may be shared with other healthcare providers involved in your care to ensure continuity of treatment.

• Example: I may contact your primary care physician to coordinate medication management.

2. For Payment:
   Your information may be used to bill and receive payment for the services provided.

• Example: I may provide necessary information to your insurance company for reimbursement.

3. For Healthcare Operations:
   Your information may be used to manage and improve my practice operations.

• Example: Reviewing records for quality assurance or auditing purposes.

Other Permitted Uses and Disclosures (No Authorization Required):

I may disclose your information without your consent in certain situations, including:

1. Legal Requirements:
   To comply with laws and regulations, such as reporting abuse or neglect or responding to court orders.

2. Public Health Activities:
   To prevent or control disease, report adverse reactions to medications, or notify individuals of exposure to contagious diseases.

3. Threats to Health or Safety:
   To prevent a serious and imminent threat to your health or the safety of others.

4. Law Enforcement Purposes:
   To respond to subpoenas, warrants, or other lawful requests.

5. Workers' Compensation:
   To comply with laws relating to workers’ compensation claims.

Uses and Disclosures Requiring Your Written Authorization:

For any use or disclosure not described above, I will obtain your explicit written authorization. You may revoke this authorization at any time in writing.

Examples include:

• Sharing psychotherapy notes.

• Using your information for marketing purposes.

• Disclosing information for non-routine purposes.

How to File a Complaint

If you believe your privacy rights have been violated, you can file a complaint with the U.S. Department of Health and Human Services:

• Online: www.hhs.gov/ocr/privacy/hipaa/complaints

• Phone: 1-800-368-1019

Complaints must be submitted in writing and describe the nature of the alleged violation. There will be no retaliation for filing a complaint.

Changes to This Notice

I reserve the right to change this Notice of Privacy Practices at any time. Updates will be effective for all PHI I maintain. You will be notified of significant changes and may request a revised copy.

Acknowledgment of Receipt:
By signing this document below, you acknowledge that you have received and reviewed this HIPAA Notice of Privacy Practices.

To exercise any of the rights listed above please message me via your Simple Practice client portal or if you are no longer an active client please email me at Lahela@realworkwellness.com.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on March 1, 2025

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