Mother and daughter keeping conversation private


I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Clinicians and administrative staff associated with Commonwealth Counseling Associates, PC (CCA) may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

  • PHI” refers to information in your health record that could identify you.
  • Treatment, Payment and Health Care Operations
    • Treatment is when your clinician provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when your clinician consults with another health care provider, such as your family physician or another psychologist.
    • Payment is when CCA obtains reimbursement for your healthcare. Examples of payment are when CCA or your clinician discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or 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 the office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  • Disclosure” applies to activities outside of the office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

CCA or your clinician may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when your clinician is asked for information for purposes outside of treatment, payment and health care operations, he or she will obtain an authorization from you before releasing this information. Your clinician will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes made about conversations during a private, group, joint, or family counseling session, which have been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

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) your clinician has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

Your clinician may use or disclose PHI without your consent or authorization in the following circumstances:

  • Child Abuse: If your clinician has reason to suspect that a child is abused or neglected, he/she is required by law to report the matter immediately to the Virginia Department of Social Services.
  • Adult and Domestic Abuse: If your clinician has reason to suspect that an adult is abused, neglected or exploited, he/she is required by law to immediately make a report and provide relevant information to the Virginia Department of Welfare or Social Services.
  • Health Oversight: The relevant Virginia licensing board has the power, when necessary, to subpoena relevant records should your clinician be the focus of an inquiry.
  • Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and your clinician will not release information without the written authorization of you or your legal representative, or a subpoena (of which you have been served, along with the proper notice required by state law). However, if you move to quash (block) the subpoena, your clinician is required to place said records in a sealed envelope and provide them to the clerk of court of the appropriate jurisdiction so that the court can determine whether the records should be released. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered.
  • Serious Threat to Health or Safety: If your clinician is engaged in his or her professional duties and you communicate to them a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and they believe you have the intent and ability to carry out that threat immediately or imminently, they must take steps to protect third parties. These precautions may include (1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18; or (2) notifying a law enforcement officer.
  • Worker’s Compensation: If you file a worker’s compensation claim, your clinician is required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.

IV. Patient’s Rights and Provider’s Duties

Patient’s Rights:

  • Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, your clinician is not required to agree to a restriction you request.
  • 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 being seen. Upon your request, your bills will be sent to another address.)
  • Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your clinician may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, your clinician will discuss with you the details of the request and denial process. You will be charged on a pro rata basis at the then current posted hourly rate for any time spent meeting with you regarding your request. You will also be charged at the then current rate for preparation and copying of the record.
  • Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your clinician may deny your request. On your request, your clinician 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 for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, your clinician will discuss with you the details of the accounting process.
  • Right to a Paper Copy – You have the right to obtain a paper copy of this notice upon request, even if you have agreed to receive the notice electronically.

Clinician’s Duties:

  • Your clinician is required by law to maintain the privacy of PHI and to provide you with a notice of his/her legal duties and privacy practices with respect to PHI.
  • Your clinician reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, your clinician is required to abide by the terms currently in effect.
  • If your clinician revises his/her policies and procedures, he/she will attempt to notify you by mail at the address available in your record.

V. Complaints

If you are concerned that your clinician has violated your privacy rights, or you disagree with a decision he/she made about access to your records, you may contact Dr. James H. Bullock, President, Commonwealth Counseling Associates, PC at 9097 Atlee Station Road, Suite 219, Mechanicsville, VA 23116

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.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on April 14, 2003

Your clinician reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI. You will be provided with a revised notice by mail at the address contained in your record.

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9202 Center Oak Court

Mechanicsville, VA 23116


Tel: 804.730.0432
Fax: 804.730.2829

Evening and Saturday hours are available by appointment.




15521 Midlothian Turnpike

 Suite 105

Midlothian, VA 23113


Tel: 804.423.1550
Fax: 804.423.1550

Evening and Saturday hours are available by appointment.




5213 Hickory Park Dr

Suite A

Glen Allen, VA 23059


Tel: 804.237.8030
Fax: 804.237.8028

Evening and Saturday hours are available by appointment.




7231 Forest Avenue

Suite 103

Richmond, VA 23226


Tel: 804.728.2138
Fax: 804.447.3352