This notice describes how health information about you or your child (as a patient of this practice)
may be used and disclosed, and how you can get access to your health information. This is
required by the privacy regulations created as a result of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
My practice is dedicated to maintaining the privacy of your health information. I am required by
law to maintain the confidentiality of your health information. I realize that these laws are
complicated, but I must provide you with the following information:

The following circumstances may require me to use or disclose your health information:
1) To public health authorities and health oversight agencies that are authorized by law to collect
information.
2) Lawsuits and similar proceedings in response to a court or administrative order.
3) If required to do so by a law enforcement official.
4) When necessary to reduce or prevent a serious threat to your health and safety or to the health
and safety of another individual or the public. I will only make disclosures to a person or
organization able to help prevent the threat.
5) If you are a member of the U.S. or foreign military forces (including veterans) and if required by
the appropriate authorities.
6) To federal officials for intelligence and national security activities authorized by law.
7) To correctional institutions and law enforcement officials if you are an inmate or under custody
of a law enforcement official.
8) For Workers’ Compensation and similar programs.

Business Associates:

• Kinetic Mind may contract with business associates and attorneys to attend to business aspects
on an as-needed basis. For example, I may contract with a company to service and maintain my
computer systems, electronical medical record, communications systems or to do my billing. In this
case, there will be a written contract in place with the business, requiring that it maintain the
security of your information in compliance with the rules of HIPAA. I will share with my business
associates only the minimum amount of personal health information necessary for them to assist
us.

Parents:

• If you are a parent of a minor, and are acting as the minor’s personal representative, I may
disclose health information about your child to you under certain circumstances. For example, if I
am legally required to obtain your consent for your child to receive treatment from my practice, I
may disclose information about your child to you. I will always inform you of new imminent threats
to safety including suicidal and homicidal thoughts and will always seek your consent for
medication treatment.
• In some circumstances, I may not disclose health information about an unemancipated minor to
you. I may protect the con0identiality of the minor regarding risk-taking behaviors including
substance abuse and sexual activity. If your child is legally authorized to consent to treatment
(without your consent) and does not request that you be treated as his or her personal
representative, I may not disclose health information about your child to you without your child’s
written authorization.

1) You have the right to obtain an accounting of disclosures of your health information, as required
to be maintained by law, by delivering a request to my office in writing. An accounting will not
include uses and disclosures of information for treatment, payment or practice administrative
purposes; disclosures or uses made to you or made at your request; uses or disclosures made
pursuant to an authorization signed by you; uses or disclosures made to family members or friends
relevant to that person’s involvement in your care or in payment for such care; or, uses or
disclosures to notify family or others responsible for your care of your location, condition, or your
death. Kathryn Bouchard PMHNP-BC reserves the right to temporarily suspend your right to receive
an accounting of disclosures to health oversight agencies or law enforcement officials, as required
by law.
2) You have the right to revoke authorizations that you made previously to use or disclose
information by delivering a written revocation to our office, except to the extent information or
action has already been taken.
3) You can request that my practice communicate with you about your health and related issues in
a particular manner or at a certain location. For example, you may ask that I contact you at home,
rather than work. I will accommodate reasonable requests.
4) You can request a restriction in my use or disclosure of your health information for treatment,
payment, or health care operations. Additionally, you have the right to request that I restrict
disclosure of your health information to only certain individuals involved in your care, or the
payment for your care, such as family members and friends. I am not required to agree to your
requests; however, if I do agree, I am bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
5) You have the right to inspect and obtain a copy of the health information that may be used to
make decisions about you, including patient medical records and billing records, but not including
psychotherapy notes. You must submit your request in writing to Kathryn Bouchard PMHNP-BC
(address above). Compliance is required within 30 days.
6) You may ask me to amend your health information if you believe it is incorrect or incomplete,
and as long as the information is kept by or for my practice. To request an amendment, your
request must be made in writing to Kathryn Bouchard PMHNP-BC (address above). You must
provide a reason that supports your request for amendment within 60 days.
7) You are entitled to receive a copy of this Notice of Privacy Practices. You may ask me to give you
a copy of this Notice at any time.
8) If you believe your privacy rights have been violated, you may file a complaint with my practice
or with the Secretary of the Department of Health and Human Services. To file a complaint with my
practice, submit it in writing to Kathryn Bouchard PMHNP-BC (address above). You will not be
penalized for filing a complaint.
9) My practice will obtain your written authorization for uses and disclosures that are not identified
by this notice or by applicable law.