Ken Fremont-Smith, MA

Registered Counselor: RC00013414
Chemical Dependency Professional: CP00002322

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


Privacy is a very important concern for all who come to this office. It is also complicated because there are federal laws, state laws, and other professional requirements. As a result, some parts of this Notice are quite detailed and you may want to read them several times to understand them. If you have any questions I (Ken Fremont-Smith) will be happy to respond. THE MOST IMPORTANT THING TO REALIZE, AS YOU STRUGGLE WITH THE TECHNICAL INFORMATION BELOW, IS THAT I AM COMMITTED TO KEEPING WHAT YOU SHARE PRIVATE, UNLESS YOU GIVE ME WRITTEN PERMISSION, OR THE LAW REQUIRES ME TO DO SO.



This notice explains how I how I handle information about you – how I use the information here in my office, how and when I might share it with other professionals and organizations, and how you can see it. I want you to know all of this so that you can make the best decisions. I am also required to tell you about this because of the privacy regulations of the federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPPA). Because this law and the laws of this state are very complicated, and I don’t want you to have to read a lot that may not apply to you, I have simplified some parts. If you have ANY questions or want to know more about anything in this Notice, please ask me. HOWEVER, I am not a lawyer. While I will advise you to the best of my knowledge, if you need specific advice, I would recommend seeking formal legal counsel.


Any time you visit me (or any clinic, hospital, or other healthcare provider), information may be collected about you and your physical and/or mental health. It may be information about your past, present or future conditions, or the treatment or services you received from me or from others, or about payment for healthcare. The information collected from you is called, in the law, PHI, which stands for Protected Health Information. This information goes into your file (or medical or healthcare record). In my office, PHI may include (but is not necessarily limited to):

  • Your history (as a child, school, work, marital and personal history)
  • Your reasons for treatment (problems, symptoms, hopes, goals)
  • Diagnoses (medical terms for your problems or symptoms)
  • A treatment plan (what I think will best help you, based on your goals)
  • Progress notes (my observations of how you are doing, and what you tell me)
  • Records I may get from others who treated or evaluated you
  • Psychological test scores and the like
  • Legal matters
  • Billing and insurance information

All this information is used for many purposes. For example, I may use it:

  • To plan your care and treatment
  • To evaluate how well treatment is working for you, and to improve it
  • To confer and collaborate with other professionals working with you (such as your family doctor)
  • To prove you actually received my services (e.g., for billing purposes)
  • For public health officials trying to improve health care in this country
  • For psychological research
  • For teaching and training other healthcare professionals

Knowing what is in your record and what it is used for lets you make better decisions about who, when, and why others should have this information.


While I am the guardian of your health record (the one I physically create), the information belongs to you. You can inspect, read, or review it.  A copy can be made for you (although you would be charged for the costs of any copying and mailing to you). In some unusual situations you cannot see all of what is in your records. If you find anything in your records that you think is incorrect, or find that something important is missing, you can ask me, in writing, to amend (or add to) your record, although in some situations I don’t have to agree to do that. I can tell you how to do this, as needed.



The HIPAA law requires me to keep your PHI private and to give you notice of my legal duties and my privacy practices, which is this form (the Notice of Privacy Practices, or NPP). Since new rules can occur, I may have to amend the NPP; any new rules will apply to all the PHI I keep from that point on. If I change the NPP I will post the new Notice in my waiting area where everyone can see. You (or anyone) can also request a copy from me at any time; and it will be posted on my website:



When your PHI is read by me this is called, in the law, “use”. If the information is shared with others outside this office, this is called, in the law, “disclosure”. Except in some special cases, when I disclose to others I share only the minimum necessary PHI needed for the purpose. The law gives you rights to know about your PHI, how it is used, and to have a say in how it is disclosed.


I use and disclose PHI for several reasons. Mostly it is for routine purposes explained below. For many uses I must inform you AND have a written Authorization from you (unless the law requires me to make the use or disclosure without your authorization). However, the law also says I am allowed to make some uses and disclosures without your consent or authorization.


1. Uses and Disclosures of PHI with your consent.

After you have read this Notice you will be asked to sign a separate Consent form to allow me to use and share your PHI. In almost all cases I intend to use your PHI or share your PHI with others in order to provide treatment to you, to arrange for payment for my services, or for some other business functions called health care operations. Together these routine purposes are called TPO, and the Consent form allows me to use and disclose your PHI for TPO. (Re-read this last sentence until it is clear, because it is very important.)

 Please note that, even where HIPAA does not require it, I will seek to obtain written authorization from you (a signed consent) to release any specific information to any individual or organization. The exceptions to this approach are under 3. below, and again in my “Office Policies” form under “Your Rights as a Client”.

1a. For treatment, payment, or health care operations (TPO).

I need information about you to provide care and services to you. You have to agree to let me collect the information and to use it and share it as necessary to care for you properly. Therefore you must sign the Consent form before I begin to treat you; if you do not agree and consent, I cannot treat you.


For treatment (T).  I use your information to provide you with psychological treatment or services, whether individual, couple, family, or group therapy; or for psychological testing, treatment planning, treatment evaluation, or measuring the effects of my services.

I may disclose your PHI to others who provide treatment to you, such as, for example, your personal physician. If I refer you for services I cannot offer, such as special testing or treatment, I may need to provide them some information about your situation/conditions. Similarly, their findings might go into my record. If you receive treatment in the future from other professionals, I may also share your PHI with them. These examples are meant to be representative, and not exclusive.

For payment (P).  I may use your information to bill you, your insurance, or others, in order to be paid for my treatment of you. If I work with insurance, I may have to discuss with your insurance company what your diagnosis is, what treatment you have received, and what future plans are. I will have to reveal dates and times of treatment, your progress, and similar information.

For health care operations (O). This is when I use your PHI for other purposes, such as looking at how to improve the services I provide (research), or supplying required information to government health agencies so they can study disorders and treatment and make plans for services that are needed. In such cases, your name and identity are removed from what I send.

 1b. Other Uses in healthcare. I may use or disclose your PHI in order to:

Set Appointment Reminders/Reschedule Appointments. If you want me to call or write to you only at your home or your work, or prefer some other method of contact, I can usually arrange that; just tell me.

Discuss Treatment Alternatives. Possible treatments or alternatives that may be of interest to you, or other benefits or services that may be of interest to you.

Do Marketing.  For example, to send you my newsletter.
Do Research To Improve Treatments. In all cases your name and any other information that identifies who you are will be removed. If identifying information is desired, this could only be done with your signed authorization.

 Work With Business Associates. I may have to release information to businesses I hire (e.g., a billing service). To safeguard your privacy, Business Associates have to have a contract with me where they have agreed to safeguard your PHI.


2. Uses and Disclosures requiring your Authorization.

If I want to use your information for any purpose besides the TPO or those described above, I need your permission on a separate Authorization form.

(If you do authorize me to use or disclose your PHI, you can cancel that permission, in writing, at any time. From that point on, I cannot use or disclose your PHI for the purposes we agreed to. Of course, this does not affect any disclosures already made while I had your authorization.)


3. Uses and Disclosures of PHI not requiring consent or authorization.

The laws require I disclose some of your PHI without your consent or authorization in certain cases, including (but not limited to):

  • To report suspected child abuse, elder abuse, or dependent adult abuse.
  • If I believe you have made a serious threat against your life or safety, or that of another person (including myself).
  • If you are in legal proceedings and I receive a court order or other lawful process that requires me to release some or all of your PHI. I will do so only after trying to discuss the situation with you or your lawyer. I may also try to get a court order to protect the information requested.
  • If I have to disclose some information to the government agencies which check on counselors to see if we are obeying the privacy laws.
  • For specific government functions, such as disclosing PHI of military personnel and veterans to government benefit programs relating to eligibility and enrollment; to Workers’ Compensation programs; to correctional facilities if you are an inmate; and for national security reasons.

4. Uses and Disclosures requiring you to have an opportunity to object.

In an emergency – where I cannot ask if you disagree – I may share information if I believe it is what you would have wanted and I believe it will help. In such cases I will tell you as soon as I can. If you don’t approve I will stop, as long as it is not against the law.


You have the right to ask me (in writing) to limit what I tell certain individuals you choose to have involved in your care (such as family members or friends). While I don’t have to agree to your request, I will try to honor it unless it is against the law.


5. An Accounting of disclosures.

Any time I disclose your PHI, I keep a record of who I sent information to, when I sent it, and what I sent. You can get a list of many of these disclosures.


IF YOU HAVE QUESTIONS OR CONCERNS about the privacy practices described above, please talk to me, call me, or e-mail me. If you have any problems with how your PHI has been handled, or if you believe your privacy rights have been violated, first contact me. You have the right to file a complaint with me; complaints must be in writing. You also have a right to file a complaint with the Secretary of the Federal Department of Health and Human Services (866-627-7748). I promise I will not limit your care here or take any actions against you because of a complaint.


I can be reached at 206-547-2590, or by e-mail at

 The effective date of this notice is April 14, 2003.