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Office Policies

Policies, HIPPA, Disclosures

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*HIPAA Policy

Your Information.  

Your Rights.  

Our Responsibilities. 


This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. 

Your Rights 

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. 

Get an electronic or paper copy of your medical record  

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.  
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. 

Ask us to correct your medical record 

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. 
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days. 

Request confidential communications 

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.  
  • We will say “yes” to all reasonable requests. 

Ask us to limit what we use or share 

  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. 
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. 

Get a list of those with whom we’ve shared information 

  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. 
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. 

Choose someone to act for you 

  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. 
  • We will make sure the person has this authority and can act for you before we take any action. 

File a complaint if you feel your rights are violated 

  • You can complain if you feel we have violated your rights by contacting us using the information on page 1. 
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting 
  • We will not retaliate against you for filing a complaint. 

Your Choices 

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. 

In these cases, you have both the right and choice to tell us to: 

  • Share information with your family, close friends, or others involved in your care 
  • Share information in a disaster relief situation 

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. 

Our Uses and Disclosures 

We can use your information without your consent for the following purposes. 

Treat you 

We can use your health information and share it with other professionals who are treating you. 

Run our organization 

We can use and share your health information to run our practice, improve your care, and contact you when necessary. 

Bill for your services 

We can use and share your health information to bill and get payment from health plans or other entities.  


Help with public health and safety issues 

We can share health information about you for certain situations such as:  

  • Preventing disease 
  • Helping with product recalls 
  • Reporting adverse reactions to medications 
  • Reporting suspected abuse, neglect, or domestic violence 
  • Preventing or reducing a serious threat to anyone’s health or safety 

Do research  

We can use or share your information for health research. 

Comply with the law 

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. 

Respond to organ and tissue donation requests 

We can share health information about you with organ procurement organizations. 

Work with a medical examiner or funeral director 

We can share health information with a coroner, medical examiner, or funeral director when an individual dies

Address workers’ compensation, law enforcement, and other government requests 

We can use or share health information about you: 

  • For workers’ compensation claims or law enforcement purposes or with a law enforcement official 
  • With health oversight agencies for activities authorized by law 
  • For special government functions such as military, national security, and presidential protective services 

Respond to lawsuits and legal actions 

We can share health information about you in response to a court or administrative order, or in response to a subpoena. 

We never market or sell personal information. 

Our Responsibilities 

  • We are required by law to maintain the privacy and security of your protected health information.  
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. 
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.  
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.  

For more information, see: 


Changes to the Terms of this Notice 

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. 


Other Instructions for Notice 

  • Effective 7/6/2016 
  • Reviewed 1/1/2019
  • Security Officer: 

Kim Fijalka


Phone Number: (509)892-1100 




Our counselors are scheduled a week or more in advance and we have a long list of people waiting to be seen, so we actively manage our appointments to fill cancellations with clients from our wait list to ensure everyone can be seen as quickly as possible.    


  • We understand that unforeseen events may occur, but if you are unable to make your appointment, a 24-hour advanced notice is required so that we can offer that time slot to someone waiting to be seen.  


  • If you arrive after the start time for your appointment, your counselor may choose to cancel the session and may consider it at Late Cancel/No Show. 



  • If you No Show (fail to show up for an appointment and do not contact your counselor or our office to cancel) or Late Cancel (fail to provide 24 hours advance notice for a cancellation), then all future appointments may be cancelled, and you may be placed back on the waitlist or moved to a counselor-availability only basis.  


  • If you have 3 canceled appointments of any kind during a 3-month period, all your future appointments may be cancelled, and you may be seen on a counselor-availability only basis or potentially be unable to schedule any future appointments with any of our counselors.  



  • If you cancel your appointment and you are able to reschedule within the same week as your initial appointment, it will NOT be considered a cancellation.   







Those Therapists with an LMHC, PhD, LICSW, LMFT or ARNP are fully licensed and can practice independently. 


LMHCA, LICSWA, LMFTA indicate provisional licensure in the State of Washington. These therapists have completed their master’s degree and are able to see clients under the supervision of a fully licensed practitioner.  


“Intern” indicates that this practitioner is not licensed and is in the process of completing a master’s or doctoral degree from an accredited university. This person is also supervised by fully licensed practitioners both at Family Essentials Counseling and within their graduate program at the university he or she is currently enrolled at.


Email, voicemail, and texting are not confidentially secure forms of communication. However, if you prefer to be contacted by any of these methods, you can release us to use these. 


According to WAC 246-810-035 (2) your therapist is allowed to keep minimal confidential notes for each session to protect your privacy. In the event of an insurance audit, the insurance company would receive a diagnosis code and minimal notations. You can release your therapist to do so upon intake.


It is the intent to provide therapeutic treatment for everyone who works with a clinician at Family Essentials Counseling. We believe that a counselor ceases to maintain a therapeutic alliance with a client when asked to testify, sit for a deposition, or write an affidavit to make recommendations to the courts. Further, clinicians are not trained to provide this type of testimony, so it is unethical to engage in these types of activities. This is not something that we are skilled at. If this is your aim in seeking counseling, please request a referral to an agency which has the skills to perform such a role.


If it ever becomes necessary during treatment to testify, write letters, or anything court-related beyond the work we would typically do when working therapeutically, please note our rates and policies below: 


$250/hour upon receipt for written letters, affidavits, recommendations. 


$2000 due upon receipt for any subpoena to sit for a deposition or court appearance. This is refundable up to one week prior to date and time of the required appearance, but as we will need to cancel all appointments for the day of the appearance and will need to prepare for testimony, it is not refundable after this point, as the work has been done and the appointments with other clients cannot be rescheduled.


It is required for children of divorce to have a copy of the visitation/custody settlement papers on file. These papers will need to be received prior to working with the child. Unless there is written legal documentation to the contrary, both parents will be invited to work with the therapist in supporting the child during the therapeutic process. (If divorce is not final, temporary orders will be accepted until final papers are filed.)


Additional Mandatory Information RCW 18.225.100: You have the right to refuse treatment and the right to choose a practitioner and treatment modality which best suits your needs. You have the right to confidentiality except the reporting of suspected abuse or neglect of a child, dependent adult or developmentally disabled person. This disclosure does not grant new rights and is not intended to supersede state or federal laws and regulations, of professional standards.  


Please also note that if you disclose intent to harm yourself or others we are legally and ethically bound to report this to authorities.  


You will be required to release information necessary for supervision, training, or other lawful purposes; the providing credit or collection of any fees due; and, that should a complaint of any nature be instituted against a provider and/or Family Essentials Counseling, or should any collection of monies due to the provider be initiated, the undersigned waives the right to confidentiality and agrees to hold the provider and/or Family Essentials Counseling harmless for any and all subsequent disclosures by such. The use of a copy of the Disclosure Statement can be used as assignment to be considered as the original and shall be valid for the duration of the therapeutic relationship or length of time needed to culminate financial or legal disputes in relation to such. 

You will be asked to sign this document, and by doing so, you (the client, patient, member, etc.) are indicating that you have read and agree with the information, agree to treatment, and have been given a copy of this document. This document is the sole agreement between client and counselor and Family Essentials Counseling and supersedes any other agreements or contracts whatsoever.  


The Washington State Department of Health may be contacted to obtain a list of or copy of the acts of unprofessional conduct listed under RCW 18.130.180 at Health Professional Quality Assurance, PO Box 47860, Tumwater, WA 98501, (360) 236-4700.