Monya Cohen, Psy.D., LLC may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your written authorization. To help clarify these terms, here are some definitions. "PHI" refers to information in your health record that could identify you. "Treatment" is when we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider such as your family physician, psychiatrist, or another therapist. "Payment" is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility coverage. "Health Care Operations" are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. "Use" applies only to activities within our group practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. "Disclosure" applies to activities within our group practice such as releasing, transferring, or providing access to information about you to other parties. "Authorization" is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.

We may use or disclose PHI for purposes outside of treatment, payment or health care operations when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your Psychotherapy Notes. "Psychotherapy Notes" are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. I will also obtain an authorization from you before using or disclosing. PHI in a way that is not described in this Notice. You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

Monya Cohen, Psy.D. LLC may use or disclose PHI without your consent or authorization in the following circumstances: This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence. Child Abuse-If there is a reason to believe that a child has been subjected to abuse or neglect, we must report this belief to the appropriate authorities. Adult and Intimate Partner Abuse-Monya Cohen, Psy.D., LLC may disclose protected health information regarding you if I reasonably believe that you are a victim of abuse, neglect, and/or self-neglect and/or exploitation. Health Oversight Activities-If I receive a subpoena from any Maryland Board of Examiners of Psychologists or Social Workers because they are investigating my practice, I must disclose any PHI requested by the Board. Judicial and Administrative Proceedings-If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and we will not release information without your written authorization or a court order. The privilege does not apply when you are being evaluated by a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

Patient's Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected health information. However, Monya Cohen, Psy.D., LLC is not required to agree to a restriction you request. Patient's Right to Receive Confidential Communications by Alternative Means and at Alternative Locations-You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing us. At your request, we will send your bills to another address.) You will be provided with a form on which to list your authorized means of communication. It will be understood that there may be times when you may provide your therapist with additional ways in which to communicate, outside of those listed on the form you have signed. It will be understood that these also will be considered patient authorized confidential communications. (For example, you are out of town and wish to speak to your therapist. In such a case, you may leave a voicemail providing your therapist with a contact number, other than those listed on your authorization form, by which to communicate with you at the location where you are.) Right to Inspect and Copy-You have the right to inspect or obtain a copy (or both) of PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. You have the right to inspect or obtain a copy (or both) of Psychotherapy Notes unless I believe the disclosure of the record will be injurious to your health. On your request, I will discuss with you the details of the request and denial process for both PHI and Psychotherapy Notes. Right to Amend-You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. At your request, I will discuss with you the details of the amendment process. Right to an Accounting-You generally have the right to receive an accounting of disclosures of PHI. At your request, we will discuss the details of the accounting process. Right to a Paper Copy-You have the right to obtain a paper copy of the notice from Monya Cohen, Psy.D., LLC upon request, even if you have agreed to receive the notice electronically. Right to Restrict Disclosures When You have Paid for Your Care Out of Pocket. You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services. Right to Be Notified if There is a Breach of Your Unsecured PHI. You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised. Therapist Duties: As your therapist, I am required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. As your therapist, I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise our polices and procedures, I will post a sign in our office and provide copies of the revised policy.

If you have questions about this notice, disagree with a decision made about access to your records, or have other concerns about your privacy rights, you may contact me at 240-293-0274. If you believe that your privacy rights have been violated and wish to file a complaint, please send your written complaint to Monya Cohen, Psy.D., LLC P.O. Box 42 , Sandy Spring, MD 20860. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. We will not retaliate against you for exercising your right to file a complaint.