James Fitzgerald Therapy, PLLC

James Fitzgerald, MS, NCC, LCMHC

359 Dorset Street, Suite 200-2

South Burlington, VT 05403


This online form should be considered electronic communication. The form is for reviewing the practitioner’s privacy policy. A more secure version of this document is available in the Client Therapy Portal through my EHR software Therapy Notes LLC.


The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. For Psychotherapists this requires little change from the practice of confidentiality that has been required of our profession prior to HIPAA. In general, the HIPAA Act gives you, the client or patient, significant new rights to understand and control how your health care information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, I have prepared this explanation of how I am required to maintain the privacy of your health information and how I may use and disclose your health information. Please note that, for the practice of psychology, these HIPAA requirements compliment rather than add any significant change to the normal and usual practice as regards record keeping and confidentiality. I may use and disclose your medical records only for each of the following purposes: treatment, payment and healthcare operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would be performing psychotherapy in this office, or making a referral to another health care provider for additional evaluation or treatment.

Payment means such activities as obtaining reimbursement services, confirming insurance coverage, billing or collection activities, and utilization review for managed care coverage and approval and/or at the request of a third party payer for your treatment (your insurance company). An example of this would be sending a bill for your psychotherapy visit to your insurance company, electronically, by mail, or by fax, sending the necessary clinical information for your insurance company to approve more sessions for coverage for you.

Health care operations include the business aspects of running a practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. I may also create and distribute de-identified health information by removing all references to any and all individually identifiable information. I may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that might be requested by or be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and I am required to honor and abide by that written request, except to the extent that I have already taken actions relying on your prior written authorization to take such actions. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to your psychotherapist.

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. I am, however, not required to agree to a requested restriction if Vermont law or Federal law indicates that to do so would be a violation of Duty to Warn Statutes of person or property, violation of mandated reporting of known abuse of a minor or child, or violation of mandated reporting of known abuse of an elderly or incapacitated person. As a psychotherapy client/patient you own the privilege of confidentiality, and no information, including your presence in therapy or the fact that you are a client, will be disclosed without your specific written permission in a release of information request.

Psychotherapy has traditionally always been more restricted in its mandated legal and ethical protection of your protected health information. HIPAA regulations do not affect any previous safeguards to your privacy as a patient, except in certain cases to strengthen them. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternate locations. – The right to inspect and copy your protected health information. – The right to amend your protected health information. – The right to receive an accounting of disclosures of protected health information. – The right to obtain a paper copy of this notice from us upon request.

I am required by law to maintain the privacy of your protected heath information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of September 1st, 2020 and I am required to abide by the terms of the Notice of Privacy Practices currently in effect. I reserve the right to change the terms of my Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that I maintain. I will post and you may request a written copy of a revised Notice of Privacy Practices from my office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with the Department of Health and Human Services, or the Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of my practice. I will not retaliate against you in any fashion for filing a complaint. Please speak with me directly or contact me for more information. For more information about HIPAA or to file a complaint:

The U.S. Department of Health and Human Services Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

(202) 619-0257 Toll Free: 1-877-696-6775