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

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

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

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 downloadable intake materials maintained in your patient record.

HOW WE MAY USE AND DISCLOSE YOUR INFORMATION

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.

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 also use or disclose information for:

• Quality improvement

• Professional consultation

• Case review

• Risk management

• Legal compliance

• Business management

When consulting with other professionals, identifying information is limited to the minimum necessary. Uses and disclosures not described in this Notice will be made only with your written authorization unless otherwise permitted or required by law.

WORKERS’ COMPENSATION (WASHINGTON STATE) — IMPORTANT

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

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

Under Washington law (including RCW 51.28.070 and RCW 51.36.060) and federal HIPAA regulations (45 CFR 164.512(l)), providers are permitted and often required to disclose relevant health information for purposes of administering a workers’ compensation claim.

This may include disclosure to:

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

• Self-insured employers and their 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 reports, chart notes, psychological evaluations, diagnoses, treatment plans, billing records, and other documentation related to your claim.

Once information is submitted to the workers’ compensation claim file, it may be accessible to multiple parties legally involved in the claim process, including the employer or employer’s representative, as permitted by law.

The provider cannot control how information is used or redisclosed by other parties once it has been lawfully released into the workers’ compensation claim file.

Because treatment occurs within the workers’ compensation system, confidentiality is more limited than in traditional private psychotherapy.

Psychological evaluations and reports generated within a workers’ compensation claim will be disclosed to the workers’ compensation insurer or claim administrator for payment and claim administration purposes and may be accessible to other authorized parties as permitted or required by federal and Washington law. Such reports may influence claim-related decisions, including authorization of treatment and benefits.

USES AND DISCLOSURES REQUIRED OR PERMITTED BY LAW

We may use or disclose your protected health information when required or permitted by federal or Washington state law. This may include disclosures for public health and safety, health care oversight, legal or administrative proceedings, or other purposes authorized by law.

If you file a complaint, grievance, or legal action against this practice, relevant information will be disclosed as necessary for defense as permitted by law.

PSYCHOTHERAPY NOTES

This practice does not maintain separate psychotherapy notes as defined by HIPAA. All documentation is maintained within the clinical record and may be disclosed as permitted or required by federal and Washington law, including workers’ compensation law.

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 PROTECTED HEALTH INFORMATION

This practice does not sell protected health information for any purpose. We will not use or disclose your protected health information for marketing or for any purpose that would constitute a sale of protected health information without your written authorization, except as otherwise permitted or required by law.

ELECTRONIC COMMUNICATIONS

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

YOUR RIGHTS REGARDING YOUR INFORMATION

You have the right to:

Access Your Records.

Request to inspect or obtain a copy of your health record (with limited legal exceptions). If maintained electronically, you may request an electronic copy where available.

Request Amendment

Request correction of factual errors or omissions.

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 fully out of pocket in full (not typically applicable in workers’ compensation cases).

Confidential Communications

Request that we contact you by alternative means or at alternative locations.

Paper Copy

Receive a paper copy of this Notice at any time.

Breach Notification

Be notified if a breach of your unsecured protected health information occurs.

Personal Representative

If you have a legally authorized personal representative (such as a court-appointed guardian or person with health care decision-making authority), that person may exercise your privacy rights as permitted by law.

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.

RECORD RETENTION

Washington law requires retention of adult records for at least eight years after termination of services/last clinical contact. Minor records are retained in accordance with Washington 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

If you believe your privacy rights have been violated, you may file a complaint without fear of retaliation. You will not be retaliated against for filing a complaint.

Please direct complaints to:
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
https://www.hhs.gov/hipaa/index.html