The Notice below is included in the paperwork completed when initiating services with this practice and describes how medical and mental health information about you may be used and disclosed and about how you can access this information.

Effective Date: 02.01.2026

NOTICE OF PRIVACY PRACTICES

OUR LEGAL DUTIES

This practice is required by law to:

• Maintain the privacy and security of your protected health information (PHI)

• Provide you with this Notice of Privacy Practices

• Follow the terms of this Notice currently in effect

• Notify you if a breach occurs that may have compromised the privacy or security of your information

• Comply with applicable federal law (including HIPAA and, when applicable, 42 CFR Part 2) and Washington State law

• Follow the duties and privacy practices described in this Notice and provide you a copy

We limit uses and disclosures of protected health information to the minimum necessary consistent with applicable law and the workers’ compensation system.

We will not use or share your information for reasons not described in this Notice unless you give written permission. You may change your mind and withdraw that permission at any time in writing. We will stop future use or sharing after we receive your request, but we cannot take back information that has already been released.

You may request and receive this Notice in paper or electronic form.

We reserve the right to change the terms of this Notice and make revised provisions effective for all protected health information we maintain. An updated copy will be available upon request, on our website at drcherylhart.com, and within intake materials.

HOW WE MAY USE AND DISCLOSE YOUR INFORMATION

Because services are provided within the workers’ compensation system, confidentiality is more limited than in traditional private-pay psychotherapy. Information related to your condition and treatment may be shared as required for claim administration, payment, and legal processes.

Treatment

We may use and disclose your health information to provide, coordinate, or manage your psychological care and related services.

This may include communicating with or sharing records with various professional stakeholders in your worker’s compensation claim:

• Referring providers

• Treating providers

• Providers to whom you are being referred

• Vocational providers

• Claim managers

• Employer

• Other professionals involved in your workers’ compensation claim

This practice provides psychological evaluation, consultation, and treatment services within the workers’ compensation system. Services may include psychological evaluations or consultations that are not followed by ongoing treatment.

When consulting with other professionals for supervision or professional consultation not directly related to claim administration, identifying information is omitted whenever possible.

Payment

We may use and disclose information to obtain authorization and payment for services.  Submission of evaluation reports, chart notes, and related documentation is required for payment and claim administration. Because this practice treats only workers’ compensation patients, billing and authorization typically involve:

• Washington State Department of Labor & Industries (L&I)

• Self-insured employers

• Third-party administrators

• Claims managers

Health Care Operations

We may use or disclose information for:

• Quality improvement

• Professional consultation

• Case review

• Risk management

• Legal compliance

• Business management

Only the minimum necessary information is shared.

WORKERS’ COMPENSATION — IMPORTANT

This practice exclusively provides services within the Washington State workers’ compensation system.

If your treatment is related to a workers’ compensation claim, your health information may be disclosed without additional authorization as permitted by federal and Washington law.

This may include disclosure to:

• Washington State Department of Labor & Industries (L&I)

• Self-insured employers and representatives

• Claims managers and third-party administrators

• Vocational rehabilitation providers

• Attorneys involved in the claim

• The Board of Industrial Insurance Appeals

• Other entities legally involved in claim administration, including employers

Information released may include chart notes, psychological evaluations, diagnoses, treatment plans, work capacity information, billing records, and other documentation related to your claim.

Once information is submitted to a workers’ compensation claim file, it may be accessible to multiple authorized parties, including the employer or employer’s representative. This practice cannot control how information is used or redisclosed once lawfully released.

Clinical opinions and documentation may be used by insurers, employers, attorneys, or administrative bodies to make decisions about treatment authorization, benefits, work status, or claim closure.

LEGAL PROCEEDINGS AND SUBPOENAS

This practice frequently receives subpoenas and legal requests for records related to workers’ compensation claims.

Disclosure of records may be permitted or required by federal or Washington law and may occur without your written authorization. When legally appropriate and feasible, you may be informed of such requests; however, additional notice is not always required.

Records may be disclosed in response to subpoenas, court orders, administrative orders, or other legal processes. Once released, this practice cannot control how the information is used or redisclosed by others.

ATTORNEY AND CLAIM-RELATED CONTACT

Attorneys representing you personally or in a workers’ compensation claim generally are not considered personal representatives under federal privacy law and typically require your written authorization before records are released directly to them. A Release of Information form is available in the patient portal under the Forms tab.

PSYCHOTHERAPY NOTES

This practice does not maintain separate psychotherapy notes as defined by HIPAA. If such notes were ever created, most uses and disclosures would require written authorization.

SUBSTANCE USE DISORDER INFORMATION (42 CFR PART 2)

This practice is not a federally assisted substance use disorder treatment program but may create, receive, or maintain records that include information relating to the diagnosis, treatment, referral for treatment, or evaluation of substance use disorders.

Some records received from residential treatment programs, Veterans Affairs facilities, military treatment facilities, or other federally assisted substance use disorder treatment programs may be protected by federal confidentiality law (42 CFR Part 2), which provides additional privacy protections beyond HIPAA.

When this practice receives records that are protected under 42 CFR Part 2:

• Such records generally may not be redisclosed without your written consent unless specifically permitted by federal law.

• Redisclosure may be permitted for treatment, payment, and health care operations if you have signed a valid written consent allowing such disclosures, or as otherwise permitted by law.

• A general authorization for release of information may not be sufficient for redisclosure of Part 2-protected records unless it specifically permits such redisclosure as required by federal law.

This practice may also assess, diagnose, document, or rule out substance use disorders as part of psychological evaluation and treatment. Such information may become part of your medical record and, when services are provided within a workers’ compensation claim, may be disclosed as permitted by federal and Washington law for purposes of administering the claim and obtaining payment.

If Part 2-protected records are lawfully disclosed for workers’ compensation purposes with appropriate authorization or as otherwise permitted by law, they may become part of the workers’ compensation claim record and accessible to authorized parties involved in claim administration. Once lawfully disclosed within the workers’ compensation system, this practice cannot control how such information is used by other authorized entities.

Substance use disorder records protected under 42 CFR Part 2 may not be disclosed or used in criminal investigations or proceedings without your written consent or a specific court order that meets federal requirements.

You may revoke any written consent for disclosure of substance use disorder information at any time, except to the extent that action has already been taken in reliance on it.

Federal law prohibits unauthorized redisclosure of substance use disorder information except as permitted by applicable federal and state law, including 42 CFR Part 2.

MARKETING AND SALE OF INFORMATION

This practice does not sell protected health information and will not use your information for marketing without your written authorization.

ELECTRONIC COMMUNICATIONS AND TELEHEALTH

This practice uses electronic communication methods such as email, text messaging, telehealth platforms, and secure patient portals when appropriate. Reasonable administrative, physical, and technical safeguards are used to protect your information; however, no electronic communication system can be guaranteed to be completely secure. Email and text messaging may carry privacy risks. Use of these methods indicates acknowledgment of those risks.

Electronic communications will be conducted in accordance with applicable federal and Washington privacy laws.

You are responsible for participating in telehealth from a private location.

Audio or video recording of sessions is not permitted without prior written consent of all parties.

YOUR RIGHTS REGARDING YOUR INFORMATION

You have the right to:

Access Your Records
Request inspection or a copy of your record. We will respond within 30 days. If maintained electronically, you may request an electronic copy where available.

Request Amendment
Request correction in writing of inaccurate or incomplete information. We respond within 60 days and will explain any denial in writing.

Accounting of Disclosures
You may request a list of certain non-routine disclosures made during the past six years. This does not include disclosures made for treatment, payment, health care operations, or routine workers’ compensation claim administration.

Request Restrictions
Request limits on certain disclosures. We must honor requests to restrict disclosure to a health plan when services are paid out of pocket in full (not typically applicable in workers’ compensation cases).

Confidential Communications
Request contact by alternative means or locations.

Breach Notification
Receive notification if a breach of unsecured PHI occurs.

Choose Someone to Act for You
If someone has legal authority (guardian, power of attorney, personal representative), that person may exercise your privacy rights, as permitted by law.

Obtain a Copy of This Notice
You may request a paper or electronic copy at any time.

SOCIAL MEDIA AND PROFESSIONAL BOUNDARIES

To protect confidentiality and maintain professional boundaries, this practice does not communicate with patients via social media or respond to social media contact requests.

RECORD RETENTION

Records are retained in accordance with Washington State law (generally at least eight years after last clinical contact for adults; minors per state law).

QUESTIONS

If you have questions about this Notice or confidentiality within the workers’ compensation system, please ask. You may also seek independent legal advice, if desired.

COMPLAINTS

You may file a complaint if you believe your privacy rights have been violated. You will not be retaliated against.

Contact:
The Practice of Cheryl O. Hart, PsyD
11010 Harbor Hill Drive #B-353
Gig Harbor, WA 98332

You may also file a complaint with:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775
www.hhs.gov/ocr/hipaa