HIPAA Privacy Practices



Effective Date-This notice is effective January 1, 2017.

Sara Ralph-LPC releases information in accordance with state and federal laws and the ethics of the counseling profession. This notice describes my policies related to the use and disclosure of protected health information (PHI) for the purposes of providing services. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.

I. My Duties

The privacy and confidentiality of your health information is very important and I am committed to protecting it to the extent I can, consistent with law and ethical standards. Your health information includes records that I create and obtain in order to provide care to you. For example, it includes a record of your symptoms, examination and test results if applicable, diagnoses, summary of treatment and referrals. Bills and other payment information is also included in the record of your health information.

This Notice tells you about the different ways I may use and disclose your health information. It also describes your rights and my obligations. I am required to:

  • maintain the privacy of your protected health information as required by law;
  • provide you with this Notice of my legal duties and privacy practices with respect to your health information that 
I collect and maintain;
  • follow the terms of my Notice that is currently in effect.

II. Uses and Disclosures of Protected Health Information – Payment, Treatment and Health Care Operations Under federal law, I am permitted to use and disclose personal health information without authorization for treatment, payment and health care operations. However, state law or the ACA’s Code of Ethics may require me to obtain your express authorization before disclosing certain portions of your record and protected health information. I may also choose to require your release of information in certain circumstances. Payment: While I am not currently working with insurance companies, I will provide a receipt to you, per your request, for you to submit to your insurance company. If your health insurance company needs more information than what is printed on your receipt, I will provide only the minimum amount of information necessary for the insurance company to process the claim. This may include the diagnosis and explanation of care provided. Treatment: For example, I may discuss certain aspects of your counseling with your psychiatrist in order to provide the best treatment and medication for you. Likewise, your psychiatrist may discuss certain medication management issues with me so I can collaborate in treatment.

III. Other Uses and Disclosures of Protected Health Information/Limitations of Confidentiality

Besides use and disclosure for treatment, payment and health care operations, I may use and disclose your personal health information without authorization for the following purposes.

  • Abuse, Neglect or Domestic Violence: I may disclose protected health information about you to a state or federal agency if I am required or permitted by law to report child or vulnerable adult abuse or neglect or domestic violence. When possible, and as consistent with my professional judgment in order to avoid harm to you or others, I will inform you of the need to make such a disclosure.
  • Judicial or Administrative Proceedings: I may disclose health information about you in the course of a judicial or administrative proceeding as required by law. For example, if a court orders me to release information, I must generally comply with the order. In some circumstances, I may be required to turn over information in response to a subpoena. If I receive a subpoena for your records, I will attempt to contact you and/or your attorney if that is feasible. Your attorney may be able to file a motion that will lead to a court order.

Law Enforcement: If authorized or required by law, I may release health information to law enforcement officials. For example, I may release information to help identify a suspect or fugitive or report a crime related to a medical emergency.

Health Oversight Activities: I may disclose health information about you to governmental, licensing, auditing or health care accrediting agencies where authorized or required by law. For example, information may be released to the state counselor licensure board if a complaint is filed against me.

Appointment Reminders and other Health Services: I may contact you to remind you of appointments or to inform you of treatment alternatives or other options and services that may be of interest to you.

Prevention of Serious Threat to Public Health or Safety: In accordance with law and ethics, I may use and disclose health information about you to prevent or minimize the risk of a serious and imminent threat to your health and 
safety or to the health and safety of another person or the public.

Minors: If you are an unemancipated minor under the law of the state of Pennsylvania, I may, in certain circumstances, disclose health information about you to a parent, guardian or other authorized person, in accordance with law and ethics.

Parents: If you are the parent of an unemancipated minor, I may disclose health information about your child to you in certain circumstances. For example, if I must legally obtain your consent in order to treat your child, when you are acting as your child’s “personal representative” under law, I may disclose health information about your child to you. In other circumstances, such as when your child is legally authorized to consent to treatment without a separate consent from you, and where the child does not request that you act as his/her “personal representative,” I may not disclose health/mental health information about your child to you without your child’s authorization.

Personal Representative: If you are an adult or emancipated minor, I may disclose health information about you to a “personal representative” authorized to act on your behalf in making health care decisions.

Research and Related Activities: I may disclose health information about you for research purposes in accordance with my legal and ethical obligations. Additionally, federal law allows us to create a “limited data set,” which does not include information such as your name, address, Social Security number. This limited data set may be shared with those who have signed a contract promising to protect the privacy of the information and to use it only for research, health care oversight and health care operations.

Worker’s Compensation/ Employee Assistance Program: I may disclose health information about you for worker’s compensation or employee assistance program as authorized or required by law. These programs provide benefits for certain work-related illnesses and injuries or employee related mental health issues.

Required by Law: I may disclose information about you when required to do so by federal, state or other applicable law.

Authorization Required for Other Uses or Disclosures: I will obtain your written authorization for any other use or disclosure of your
protected health information. You have the right to revoke any authorization, in writing and in accordance with this Notice, to the extent that action has not been taken in reliance on the authorization. Psychotherapy notes are not among the records that you may, by law, review or copy, unless I believe it is in your best interests to access them. I will be happy to discuss the issue of psychotherapy notes with you if you have any questions.

Your Rights Regarding Health Information

You have certain rights regarding health information that I create and maintain about you. These rights include:

  • Right to Inspect and Copy. With certain exceptions (such as psychotherapy notes as described above, information collected for certain legal proceedings and health information restricted by law), you have the right to inspect and/or receive a copy of your records. If I am unable to accommodate your request, I will inform you in writing of the reason for the denial and your right, if any, to request a review of the denial. I may charge you a reasonable fee for copying your records.
  • Right to Request Communication by Alternative Means. If you would like me to communicate with you in a 
certain way (e.g., by leaving a message on your office phone number) or at a certain location (e.g., home only), I will make efforts to accommodate such requests for confidential communications as long as they are reasonable. I may request that you give me an alternative means to reach you, especially if there is an emergency. If I am unable to contact you using your requested means, I may contact you using any information I have.
  • Right to Request Restrictions. You have the right to request that I restrict or limit certain uses and disclosures of information. You may be asked to submit this request in writing. However, I am not required to agree to your request. I will let you know whether I am able to honor your request.
  • Right to Receive a Paper Copy of this Notice. You have the right to request a paper copy of this Notice at any time, even if you have agreed to receive it electronically. 
In order to make any requests or exercise any rights set forth above, you must submit your request in writing to: Sara Ralph-LPC, 26 Summit Grove Ave, Suite 211, Bryn Mawr, PA 19010.

You may also contact Sara Ralph by phone or e-mail during normal office hours. Further contact information is set forth in Section V, immediately below this section. Sara can be reached at 484-442-0478 or by e-mailing her at sara@sararalphlpc.com.

Questions or Complaints

If you believe that your privacy rights have been violated, you may file a written complaint and address it to Sara Ralph, LPC (listed in section VI above). If that does not satisfy your concern, you may complain to the Secretary of Health and Human Services (HHS). Instructions for filing a complaint with the appropriate office for your region can be found at https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html. Or, you may call 1-800-368-1019 and request instructions for filing a complaint. There will be no retaliation for filing a complaint.

Future Changes to this Notice and My Privacy Practices

I reserve the right to amend the terms of my privacy practices and policies and this Notice. If this Notice is revised, the changed terms will apply to all health information about you, including information obtained before the effective date of the revised Notice. Any materially revised Notice will be distributed to all clients, posted in my waiting area and posted on my website.


As a client of Sara Ralph-LPC, you have the following rights:

  • To be treated with dignity and respect at all times. You will not be subjected to harsh or unusual treatment or be 
deprived of any civil rights while a client of Sara Ralph;
  • To expect that a licensee has met the minimal qualifications of training and experience required by state law;
  • To examine public records maintained by the Board and to have the Board confirm credentials of a license.
  • To obtain a copy of the Code of Ethics;
  • To report complaints to the Pennsylvania State Board of Social Workers, Marriage and Family Therapists and Professional Counselors;
  • To be informed of the cost of professional services before receiving the services;
  • To be assured of privacy and confidentiality while receiving services as defined by rule and law, including the following exceptions:
  1. Reporting suspected child abuse
  2. Reporting imminent danger to client or others;
  3. Reporting information required in court proceedings or by client’s insurance company, or other relevant agencies;
  4. Providing information concerning licensee case consultation or supervision;
  5. Defending claims brought by client against licensee; 
  6. In the event of an emergency when I would tell emergency personnel your name.
  • To be free from being the object of discrimination on the basis of race, religion, gender, or other unlawful category while receiving services.

As a client of Sara Ralph-LPC, you have the following responsibilities:

  • To provide accurate and complete information concerning your present complaints, present/past medical/personal history, and other matters relating to your current condition and life circumstances.
  • To make it known to the therapist whether he/she comprehends clearly the course of treatment and what is 
expected from him/her.
  • To read all handouts: Informed Consent for Treatment/Policies & Procedures, Adolescent Informed Consent for Treatment (if applicable), Client Notice of Privacy Practices, Client Rights and Responsibilities, Social Media Policy,  Client Release of Information Forms, Credit Card Authorization Form (if applicable).
  • To keep appointments and notifying the therapist at least 24 hours in advance if you are unable to make your appointment.
  • To adhere to treatment recommendations. While entering into therapy is voluntary, during the course of your care, your therapist will make recommendations that are specific to your presenting problem and circumstance. While there are benefits to following these recommendations, choosing not to adhere to them could result in consequences. Those consequences will be discussed in greater detail during the session.
  • To pay all fees incurred for treatment services at the time of service.

As a client of Sara Ralph-LPC, I acknowledge that I have been given the Privacy Notice required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that prescribes legal duties and privacy practices to protect the privacy of my individually identifiable health information, by Sara Ralph-LPC. I also acknowledge that my therapist verbally explained the HIPAA laws and my client rights.