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ADHD & Autism Psychological Services and Advocacy Notice of Privacy Practices




ADHD & Autism Psychological Services and Advocacy, PLLC (AAPSA) may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

PHI” refers to information in your health record that could identify you. “Treatment, Payment and Health Care Operations”

  • Treatment is when AAPSA provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist.
  • Payment is when AAPSA obtains reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
  • Health Care Operations are activities that relate to the performance and operation of our practice. Examples of healthcare operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, case management, and care coordination.
  • Use” applies only to activities within our [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  • Disclosure” applies to activities outside of our [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.


AAPSA may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes we have made about conversations between you and members or our clinical staff during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) We have relied on that authorization; or (2) the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy. However, if you are paying out of pocket or in full for services being provided, you may request to revoke all authorizations to a health plan, unless it is being provided for treatment purposes or is required by law.


AAPSA may use or disclose PHI without your consent or authorization in the following circumstances:

  • Child Abuse: If, in the professional capacity of your licensed clinician, a child comes before us which we have reasonable cause to suspect is an abused or maltreated child, or we have reasonable cause to suspect a child is abused or maltreated where the parent, guardian, custodian or other person legally responsible for such child comes before us in our professional or official capacity and states from personal knowledge facts, conditions or circumstances which, if correct, would render the child an abused or maltreated child, your licensed clinician must report such abuse or maltreatment to the statewide central register of child abuse and maltreatment, or the local child protective services agency.
  • Health Oversight: If there is an inquiry or complaint about the professional conduct of your licensed clinician to the New York State Board for Psychology, I must furnish to the New York Commissioner of Education your confidential mental health records relevant to this inquiry.
  • Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that have provided by AAPSA to you and/or the records thereof, such information is privileged under state law, and we must not release this information without your written authorization, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. We must inform you in advance if this is the case.
  • Serious Threat to Health or Safety: AAPSA may disclose your confidential information to protect you or others from a serious threat of harm by you.

  • Worker’s Compensation: If you file a worker’s compensation claim, and you are being treated by AAPSA for the issues involved with that complaint, then we must furnish to the chairman of the Worker’s Compensation Board records which contain information regarding your psychological condition and treatment.


Patient’s Rights:

  • Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, AAPSA is not required to agree to a restriction you request.
  • Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are in treatment with ADHD & Autism Psychological Services & Advocacy, PLLC. Upon your request, we will send your bills to another address.)
  • Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.
  • Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
  • Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, we will discuss with you the details of the accounting process.
  • Right to a Paper Copy – You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.
  • Breach Notification – If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.

Psychologist’s Duties:

  • We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
  • We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
  • If we revise our policies and procedures, we will provide you with such revisions via Patient Portal, email, or mail.


If you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns about your privacy rights, you may contact Dr. Andy Lopez-Williams, President and CEO, ADHD & Autism Psychological Services and Advocacy, PLLC at 315-732-3431.

If you believe that your privacy rights have been violated and wish to file a complaint with us, you may send your written complaint to: Dr. Andy Lopez-Williams, President and CEO, ADHD & Autism Psychological Services and Advocacy, PLLC. 122 Business Park Drive, Suite 1, Utica NY 13502

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. We can provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule. We will not retaliate against you for exercising your right to file a complaint.


This notice is effective as of September 2013.