Leah Zerfoss, LICSW
Path of Hope Northwest, PLLC
4423 South 3rd Ave
Everett, WA 98203
Phone: 425-967-8325
Email: leah@pathofhopenw.com

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I understand that health information about you and your health care is personal and I am committed to protecting your health information. I keep a record of the care and services you receive from me in order to provide you with quality care and to comply with certain legal requirements. I will not disclose your record to others unless you direct me to do so or unless the law authorizes or compels me to do so. You may see your record or get more information about it at 4423 South 3rd Ave, Everett, WA 98203. This notice applies to all of the records of your care generated by this mental health care practice.

Information about you that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will make available a revised Notice of Privacy Practices by sending you an electronic copy, sending a copy to you in the mail upon your request, or providing one to you in person

HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or consultants and with other treatment team members. Disclosures for treatment purposes are not limited to the minimum necessary standard, because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

For Payment. I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. I may use or disclose, as needed, your PHI in order to support business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing or bookkeeping services) provided I have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

Health Oversight. I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors) and peer review organizations performing utilization and quality control. If I disclose PHI to a health oversight agency, I will have an agreement in place that requires the agency to safeguard the privacy of your information.

Required by Law. I may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. Examples of this type of disclosure include healthcare licensure related reports, public health reports, and law enforcement reports. Under the law, I must make certain disclosures of your PHI to you upon your request. In addition, I must make disclosures to the US Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of privacy rules.

Abuse or Neglect. I may disclose your PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect. However, the information disclosed is limited to only that information which is necessary to make the required mandated report.

Judicial and Administrative Proceedings. I may disclose your PHI pursuant to a subpoena, court order, administrative order or similar process. My preference is to obtain an authorization from you before doing so.

Deceased Clients. I may disclose PHI regarding deceased clients for the purpose of determining the cause of death, in connection with laws requiring the collection of death or other vital statistics, or permitting inquiry into the cause of death.

Medical Emergencies. I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. I will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Criminal Activity or Threats to Personal Safety. I may disclose your PHI to law enforcement officials if I reasonably believe that the disclosure will avoid or minimize an imminent threat to the health or safety of yourself or any third party.

Compulsory Process. I may be required to disclose your PHI if a court of competent jurisdiction issues an appropriate order, and if the rule of privilege has been determined not to apply. I may be required to disclose your PHI if I have been notified in writing at least fourteen days in advance of a subpoena or other legal demand, no protective order has been obtained, and a competent judicial officer has determined that the rule of privilege does not apply.

Essential Government Functions. I may be required to disclose your PHI for certain essential government functions. Such functions include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs.

Public Health. If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Law Enforcement Purposes. I may be authorized to disclose your PHI to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person’s death, if I suspect that criminal activity caused the death; (5) when I believe that protected health information is evidence of a crime that occurred on my premises; and (6) in a medical emergency not occurring on my premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.

Research. PHI may only be disclosed after a special approval process or with your authorization.

Verbal Permission. I may also use or disclose your information to family members that are directly involved in your treatment with your documented verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that I have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (1) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (2) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (3) disclosures that constitute a sale of PHI; and (4) other uses and disclosures not described in this Notice of Privacy Practices.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your request in writing or by email to Leah Zerfoss, LICSW at Path of Hope Northwest, PLLC, 4423 South 3rd Ave, Everett, WA 98203, or email leah@pathofhopenw.com.

• Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set.” A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you, or if the information is contained in separately maintained psychotherapy notes. I may charge you a reasonable cost-based fee for the copying and transmitting of your PHI. I can deny you access to your PHI in certain circumstances. In some of those cases, you will have a right of recourse to the denial of access. Please contact me if you have questions about access to your medical record. You may also request that a copy of your PHI be provided to another person.
  
  

• Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am not required to agree to the amendment. If I deny your request for amendment, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy. Please contact me if you have any questions.
  
  

• Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures that I have made of your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I may charge you a reasonable cost-based fee if you request more than one accounting in any 12-month period.
  
  

• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for in full out of pocket. In that case, I am required to honor your request for a restriction.
  
  

• Right to Request Confidential Communication. You have the right to request that I communicate with you about health matters in a certain way or at a certain location. I will accommodate reasonable requests. I may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. I will not ask you for an explanation of why you are making the request.
  
  

• Breach Notification. If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself.
  
  

• Right to a Copy of this Notice. You have the right to a paper copy of this notice and you have the right to get a copy of this notice by email. Even if you have agreed to receive this notice via email, you also have the right to request a paper copy of it.
  
  

Legal Rights of Teens Ages 13 and Older in Washington State

In Washington State, individuals aged 13 and older have specific legal rights concerning their health care, including mental health services. These rights impact confidentiality, consent, and access to treatment:

• Right to Consent: Teens 13 years or older can consent to outpatient mental health treatment without parental permission, including counseling and therapy. This means that teens can seek mental health care independently.
  
  

• Confidentiality: The law protects the privacy of teens’ health records, including mental health treatment. Health care providers, including therapists, must keep a teen’s health information confidential and cannot disclose it to parents or guardians without the teen’s consent—except in certain situations where there is a risk of harm to the teen or others.
  
  

• Access to Medical Records: Teens aged 13 and above have the right to access their own medical and mental health records. They can request copies of their health information, though in some cases, providers may limit access if sharing information could cause harm.
  
  

• Exceptions: Confidentiality may be broken without teen consent if there is a concern about abuse, neglect, danger to self or others, or if required by law.
  
  

• Communication with Parents: While parents generally do not have automatic access to a teen’s mental health information, therapists encourage family involvement when appropriate and with the teen’s agreement, to support treatment goals.
  
  

Understanding these rights is essential for empowering teens to seek help while respecting their privacy and promoting their wellbeing.

COMPLAINTS

If you believe I have violated your privacy rights, you have the right to file a complaint in writing and email or send a letter to Leah Zerfoss, LICSW at Path of Hope Northwest, PLLC, leah.pathofhopenw.com or 4423 South 3rd Ave, Everett, WA 98203 or with the Secretary of Health and Human Services at 200 Independence Avenue SW, Washington, DC 20201 or by calling (202) 619-0257. I will not retaliate against you for filing a complaint.

The effective date of this Notice is July 1st, 2025.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of the HIPAA Notice of Privacy Practices.