Full notice of Privacy Practices for Joey Pickering, LMHC

IMPORTANT: THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. If you have any questions about this Notice of Privacy Practices, please contact me at info@JPickeringLMHC.com. Who Will Follow This Notice Of Privacy Practice: This notice describes the privacy practices of the medical practices within Joey Pickering, LMHC ( a "Practice") and that of: - All medical providers, ARNP’s, LMHC, LMHCA’s, nurses, employees, staff, volunteers, students or others a Practice allows to help you while you are a patient. - Any health care professional or employee, volunteer, student who is duly authorized to enter information into your medical record(s).- All current and future affiliated medical practices, all current and future Practice locations. - TheraNest my Electronic Health Records system and DoxyMe a telemedicine software (or Zoom per its HIPAA compliant subscription option). These individuals and entities will share your medical information as necessary to carry out treatment, payment and health care operations relating to the uses and disclosures of the Practices. Pledge Regarding Medical Information: I understand that medical information about you and your health is personal. I am committed to protecting medical information about you. I create a record of care and services you receive at the Practice. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the Practice, whether made by Practice personnel or your personal medical provider. This notice will tell you about the ways in which I may use and disclose medical information about you. I also describe your rights and certain obligations I have regarding the use and disclosure of medical information. The Practice and all associates at all locations are required by law to maintain the privacy of patients’ Protected Health Information (PHI) and to provide individuals with the following Notice of the legal duties and privacy practices with respect to medical information. I am required to abide by the terms of this Notice. I reserve the right to change the terms of this Notice and these new terms will affect all medical information that I maintain at that time. I am required to notify you following a breach of your unsecured medical information. The Practice may not require individuals to waive their rights under HIPAA Privacy Regulations as a condition of treatment, payment, enrollment in a health plan, or eligibility of benefits. In certain circumstances I may use and disclose medical information about you without your written consent: For Treatment: I may use medical information about you to provide you with medical treatment or services. I will disclose medical information about you to doctors, nurses, technicians, students in health care training programs, or other personnel who are involved in taking care of you. For example, a medical provider treating you may need to coordinate care with another facility and may release or receive information from them or to them. I may disclose health information about you to people outside the Practice who provide your medical care like nursing homes or other medical providers office. For Payment: I may use and disclose medical information about you so that the treatment and services you receive at a Practice may be billed to and payment may be collected from you, an insurance company or a third party. For Health Care Operations: I may use and disclose medical information about you for the operations of the Practice. These uses and disclosures are necessary to run the Practice and make sure that all our patients receive quality care. For example, I may use medical information to review our treatment and services and to evaluate our staff in caring for you. I may also combine medical information about many Practice patients to decide what additional services the Practice should offer, what services are not needed, and whether certain new treatments are effective. I may also disclose information to doctors, nurses, technicians, medical students, and other Practice personnel for review and learning purposes. I may also combine the medical information I have with medical information from other Practice entities to compare how I am doing and see where I can make improvements in the care and services I offer. I may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. I may also disclose your medical information to other providers or health plans for certain health care operations purposes of that entity, but only if that entity has a relationship with you. Business Associates: I may use or disclose your medical information to an outside company that assists us in operating the Practices. They perform various services for us. This includes, but is not limited to, auditing, accreditation, legal services, and consulting services. These outside companies are called "business associates" and they contract with us to keep any medical information received from us confidential in the same way I do. These companies may create, receive, transmit, or maintain medical information on our behalf. Family Members and Friends: I take very seriously that you may choose to share with us information that you withhold from family, friends, coworkers, school or other individuals or entities. I may if it is deemed necessary disclose medical information to them or another individual who is involved in your healthcare. If you are not present or are incapacitated, or if is an emergency or disaster relief situation, I will use our professional judgement to determine whether disclosing limited medical information is in your best interest under the circumstances. I may disclose medical information to a family member, relative, or another person who was involved in the health care or payment for health care of a deceased individual if not inconsistent with the prior expressed preferences of the individual that are known to the Practice. But you have the right to request a restriction on our disclosure of your medical information to someone who is involved in your care. Appointment Reminders: I may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care. If you do not wish us to contact you about appointment reminders, you may speak to one of our staff or email us at info@JPickeringLMHC.com Required or Permitted by Law: I may use or disclose your medical information when required or permitted to do so by federal, state, or local law. However, I will only release the minimum necessary information as required by law. To Prevent a Serious Threat to Health or Safety: Consistent with applicable laws, I may disclose your medical information if disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Disclosures to You: Upon a written request by you, I may use or disclose your medical information in accordance with your request. Limited Data Sets: I may use or disclose certain parts of your medical information, called a “limited data set”, for purposes such as research, public health reasons or for health care operations. I would disclose a limited data set only to third parties who have provided us with satisfactory assurances that they will use or disclose your medical information only for limited purposes. Disclosures to the Secretary of Health and Human Services: I might be required by law to disclose your medical information to the Secretary of the Department of Health and Human Services, or his/her designee, in the case of a compliance review to determine whether I am complying with privacy laws. De-Identified Information: I may use your medical information or disclose it to a third party whom I have hired, to create information that does not identify you in any way. Once I have de-identified your information, it can be used or disclosed in any way according to law. Communications Regarding Our Services or Products: I may use or disclose your medical information to make a communication to you to describe a health-related product or service of the Practice. In addition, I may use or disclose your medical information to tell you about products or services related to your treatment, case management or care coordination, or alternative treatments, therapies, providers, or settings of care for you. I may occasionally tell you about another company’s products or services but will use or disclose your medical information for such communications only if they occur in person with you. Disclosures of Records Containing Drug or Alcohol Abuse Information: Because of federal law, I will not release your medical information if it contains information about drug or alcohol abuse without your written permission except in very limited situations. Disclosures of Mental Health Records: If your records contain information regarding your mental health, I am restricted in the ways I may use or disclose them. I can disclose such records without written permission only in the following situations: • If the disclosure is made to you (unless it is determined by a physician that the release would be detrimental to your health); For payment purposes; • For data collection, research, and monitoring managed care providers if the disclosure is made to the division of mental health; For law enforcement purposes or to avert a serious threat to the health and safety of you or others; To a coroner or medical examiner;• To satisfy reporting requirements;• To satisfy release of information requirements that are required by law;• To another provider in an emergency;• For legitimate business purposes;• Under a court order;• To the Secret Service if necessary to protect a person under Secret Service protection; and• To the Statewide waiver ombudsman. Disclosures of Medical Information of Minors: Under Washington state law, I cannot disclose the medical information of minors to non-custodial parents if a court order or decree is in place that prohibits the non-custodial parent from receiving such information. However, I must have documentation of the court order prior to denying the non-custodial parent such access. Emergency Treatment Situations: I may use or disclose medical information about you in an emergency treatment situation where substantial barriers to communicating with you exist. Suspected Abuse or Neglect: I may disclose your medical information to a government authority that is authorized by law to receive reports of abuse, neglect, or domestic violence. Additionally, as required by law, if I believe you have been a victim of abuse, neglect, or domestic violence, I may disclose your protected health information to a governmental entity authorized to receive such information. Special Situations: Coroners, Medical Examiners and Funeral Directors: I may release your medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. I may also release your medical information to a funeral director, as necessary, to carry out his/her duties. Health Oversight Activities: I may disclose your medical information to a health oversight agency for activities authorized by law. For example, these oversight activities may include audits; investigations; inspections; licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and government agencies that ensure compliance with civil rights laws. Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, I may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. Except for disclosures to another provider for your treatment, the information disclosed will be limited to your contact information or physical characteristics. Law Enforcement: Under certain conditions, I may disclose your medical information to law enforcement officials for law enforcement purposes. These law enforcement purposes include, by way of example, (1) responding to a court order or similar process; (2) as necessary to locate or identify a suspect, fugitive, material witness, or missing person; (3) reporting suspicious wounds, burns or other physical injuries; or (4) as relating to the victim of a crime. Lawsuits and Other Legal Proceedings: I may disclose your medical information in the course of any judicial or administrative proceeding or in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized). If certain conditions are met, I may also disclose your medical information in response to a subpoena, a discovery request, or other lawful process. Military and Veterans: If you are a member of the Armed Forces, I may release medical information about you as required by military command authorities. I may also release medical information about foreign military personnel to the appropriate foreign military authority. National Security and Intelligence Activities: I may release your medical information to authorized federal officials for lawful intelligence, counterintelligence, and other national security activities authorized by law. I may release medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or for conducting special investigations. Public Health Activities: I may use or disclose your medical information for public health activities that are permitted or required by law. For example, I may disclose your medical information in certain circumstances to control or prevent a communicable disease, injury or disability; to report births and deaths; and for public health oversight activities or interventions. I may disclose your medical information to the Food and Drug Administration (FDA) to report adverse events or product defects, to track products, to enable product recalls, or to conduct post-market surveillance as required by law or to a state or federal government agency to facilitate their functions. I also may disclose protected health information, if directed by a public health authority, to a foreign government agency that is collaborating with the public health authority. Research: The Practice may use and share your health information for certain kinds of research. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. In some instances, the law allows us to do some research using your medical information without your approval. Workers' Compensation: I will disclose your health information that is reasonably related to a worker's compensation illness or injury following written request by your employer, worker's compensation insurer, or their representative. Other Uses and Disclosures of Medical Information: Most uses and disclosures of psychotherapy notes, uses and disclosures of medical information for marketing purposes and disclosures that constitute the sale of medical information require your written authorization. Other uses and disclosures of your medical information that are not described above will be made only with your written authorization. If you provide the Practice with an authorization, you may revoke the authorization in writing, and this revocation will be effective for future uses and disclosures of medical information. However, the revocation will not be effective for information that I have used or disclosed in reliance on the authorization. Your Rights Regarding Your Medical Information: You have the following rights regarding medical information the Practice maintains about you: Right to Access, Inspect and Obtain a Copy Your Own Medical Information: You have the right to access, inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. Psychotherapy notes and mental health records may be entitled to additional protection as required by law. You have the right to obtain an electronic copy of your electronically maintained medical records if those records are readily producible in the electronic form or format you request. To access, inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing at the address at the bottom of this Notice. If you request a copy of your medical information, the copy or summary will be provided usually within thirty (30) days of your request. Please be sure to indicate if you desire a paper or electronic copy. I may charge a reasonable cost-based fee for copying, mailing, or other supplies associated with your request. I may deny your request to access, inspect and copy in certain very limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by us will review your request and denial. The person conducting the review will not be the person who denied your request. I will comply with the outcome of the review. Right to Request Restrictions: You have the right to request us to restrict or limit the use or sharing of certain health information for treatment, payment, or our operations. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that I not use or disclose information about a surgery you had. For any services for which you paid out-of-pocket in full, I will honor your request to not disclose information about those services to your health plan, provided that such disclosure is not necessary for your treatment. In all other circumstances, I am not required to agree with your request. If I do agree, I will comply with your request unless the information is needed to provide you emergency treatment. To request or terminate restrictions, you must make your request in writing and email us at info@JPickeringLMHC.com. In your request you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. I reserve the right to terminate any previously agreed-to restrictions (other than a restriction I am required to agree to by law). I will inform you of the termination of the agreed-to restriction and such termination will only be effective with respect to medical information created after I inform you of the termination. Right to Request Confidential Communications: You have the right to request that I communicate with you about medical matters in a certain way or at a certain location. For example, you may request that I contact you only at work or by mail. To request confidential communications, you must make your request in writing at info@JPickeringLMHC.com. I will not ask the reason for your request. I will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Right to Amend: If you feel that medical information, I have about you is incorrect or incomplete, you may ask us to amend the information, for as long as I maintain the information. To request an amendment, your request must be made in writing at info@JPickeringLMHC.com. In addition, you must provide a reason that supports your request. I may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, I may deny your request if you ask us to amend information that: - Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;- Is not part of the medical information kept by or for the Practice;- Is not part of the information which you would be permitted to inspect and copy; or - Is accurate and complete. The Practice personnel who maintain the information will respond to your request within 60 days after you submit the written amendment request form. If I deny your request, I will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If I accept your request to amend the information, I will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information. Right to an Accounting: You have the right to request an “accounting of disclosures.” This is a list of the disclosures that I have made of your medical information. To request this list or accounting of disclosures, you must submit your request in writing at info@JPickeringLMHC.com. Your request must state a time period which may not include dates more than six years prior to your request. Your request should state in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, I may charge you for the costs of providing the list. I will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Complaints: You may submit any complaints with respect to violations of your privacy rights to the Joey Pickering, LMHC. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services if you feel that your rights have been violated. There will be no retaliation from The Practice for making a complaint. Right to a Paper Copy of this Notice: Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may ask us for a copy of this notice at any time. You may also obtain a copy of this notice via the Practice’s website: JPickeringLMHC.com. Changes to this Notice: If I make a material change to this Notice, I will provide a revised Notice available at our website under FAQ’s. Other Uses of Medical Information: Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose the medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, I will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that I am unable to take back any disclosures I have already made with your permission.ur text here...


Thank you for choosing to pursue therapy services with me, Joey Pickering, LMHC. Although I am a private practice clinician, my business resides within transMISSION wellness – a group of like-minded providers that have come together to offer mental and physical health services. Each provider is their own business entity; however, we share a common set of values. We respect all genders, all sexualities, and all relationship styles.

SCOPE OF TREATMENT: I am a licensed mental health counselor in Washington state (LH 00010832). I received my master’s degree from Antioch University and a bachelor’s degree from the University of Washington. I’m a member of multiple professional associations from WPATH and other Washington State chapters for counselors. I also collaborate with a colleague to bring continuing education to other mental health providers on best practices when working with trans & non-binary and polyamorous clients. Our sessions may utilize ACT (Acceptance and Commitment Therapy) and Individual Psychology stemming from Adlerian theory. Both are personal goal focused approaches where behavior has meaning and holds the potential for identifying motivators toward value-based life directions. It believes all human beings strive to belong in society, feel connected to others, and generally be of purpose. I’m not able to prescribe medication, however if I feel that there are concerns outside the scope of talk therapy, I will refer you to a physician/psychiatrist for further assessment. Substance abuse is not treated but can be referred to a provider that can support your recovery. There are instances in which my experience levels and the model used here will not be clinically appropriate for a client’s needs. In these cases, an open discussion about my scope of practice and the most ethical treatment match will be addressed and a referral to other providers given.

SESSION FORMAT & FEES Sessions are 55 minutes in length unless arranged differently for clinical reasons or directed by your insurance constraints. Some insurances are considered in-network and others may reimburse as out-of-network. Out-of-network is patient responsibility; I can provide a Superbill for your records. Insurance companies require a diagnostic code that reflects medical necessity. This code is reflected in the currently used Diagnostic Statistical Manual. You are responsible for understanding your plan and understanding deductibles and covered services. Payment is due at time of service unless otherwise arranged. New client intake session is $175. Session fees are $150. Endorsement letters for previous non-active clients are $50. For current and new clients, endorsement letter assessments occur within a regular session hour and are $150 unless otherwise arranged. I am able to keep a credit card number on file securely for your convenience. Check, cash, and cards are accepted. Any charge not covered by insurance is considered patient responsibility. This includes copays, coinsurance, deductibles, and denied claims. 24 hour notice is required for canceling an appointment. Less than 24 hour notice will result in a full session fee of $150 as this hour is held specifically for you. This cannot be reimbursed by your insurance. All balances must be discussed and/or cleared before next session begins. I understand fees and cancellation policies. In cases of after hour crisis situations or medical emergency, please call 911 or the Crisis Clinic at 866-427-4747.

PRIVACY: I do not sell any client information. Voicemails and emails are typically utilized for client/provider communications. Please know these are not guaranteed confidential. Client contact information, insurance ID’s, ROI’s, billing invoices, and session notes will be kept in secure file cabinets and/or on HIPAA protected cloud storage. In the case of a breech, you will be notified as soon as possible, the weakness in storage assessed, and corrections made to ensure safety will be taken. All discussions during the course of therapy are confidential. Information may only be released through a signed “release of information” form by the person in treatment or by their legal guardian for those clients under 13 years of age. However, counselors are mandated reporters and there are times when confidentiality must be broken. It is required by law that information related to the following can be released without consent: • Disclosure of abuse or neglect of a child or dependent elder (physical, emotional, sexual) • A believable indication that you may seriously harm yourself or someone else • Involuntary commitment due to need for mental health assessment • A court or other documented state agency has ordered me to do so • During case consults with a private supervisor – names will be kept anonymous • In addition, insurance companies can request private client information at their discretion at any time, without a signed release, for reasons such as quality control or claims disputes. If I feel that you are in danger of harming yourself or someone else, I will take the steps necessary to see to your safety – this may include suggesting more frequent sessions, suicide assessments, written safety planning, providing crisis contacts, calling 911 together, notifying emergency contacts, or calling your physician noted in a previously signed release form. Because I am a solo provider, I cannot offer after hours or additional wrap-around supports. If it is determined that your mental health is declining beyond my scope or severe risk of suicidality, a referral to an agency or facility will be made in addition to a possible recommendation to the emergency room. I understand confidentiality and circumstances when it may be breached.

THERAPY FIT: Therapy can be extremely helpful, but not guaranteed. As an actively participating client, you get what you put into it with your commitment to change and practice new skills outside of sessions. Therapy is voluntary. You have the right to choose a counselor that best fits your needs. If you feel that I am not a good match, let’s openly discuss it. If we find termination of services is imminent, three referral names will be made that you have the option of contacting. A final closing session is often helpful but not required. You have the right to terminate services any time you choose. You will be responsible for any outstanding balances at that time. If you have concerns about the quality of treatment or my behavior, please feel free to discuss this directly with me. If you feel I have been unethical you have the right to contact the Department of Health: Health Services Quality Assurance Division, PO Box 47857, Olympia, WA, 98054; 360- 236-4700 or via email: HSQAComplaintintake@doh.wa.gov.

LEGAL INVOLVEMENT: In order to avoid dual relationships and conflicts of interest, I will provide you or your child with clinical services only. I do not intend to become involved in legal disputes such as personal injury lawsuits, divorce proceedings, dependency hearings or custody battles. These proceedings erode the client-therapist relationship and compromise you or your child’s ability to be honest during treatment. It also may enable your confidential session content to be under scrutiny. In addition, I do not participate in evaluation for adoption home studies or evaluations of parental fitness to adoption or State agencies. If for any reason I am legally required to provide expert testimony or documentation for a legal dispute, the party responsible for my participation agrees to reimburse me at $150 per hour, regardless of any previous sliding scale session rate, to cover time, travel, reports, and other case-related costs. Paper documents will have a per page fee set at the state’s standard rate at that time.

SOCIAL MEDIA: Texting or messaging through social networking sites are not guaranteed secure and may not be read in a timely manner. Engaging with your therapist in this way could compromise your confidentiality. All correspondence has the potential to become part of your legal medical record and may be documented or archived in your medical file. This includes emails, texts, phone logs, and mai l correspondence. We may cross paths while out in the community as Seattle is rather small and I’m often present at volunteer and informational events within the LGBTQ community, etc. If I see you outside the office, I cannot initiate contact first. It is unethical and not confidential for your session content to be discussed outside of sessions and it is recommended for your own privacy to not to do so nor through any form of social media. I will not and cannot “friend” you of “follow” you on social media. Again, this compromises your confidentiality and is unethical for me as your therapist to pursue an online social connection. I understand and acknowledge the confidentiality limitations in using email and/or text messaging and consent to do so at my own discretion.

CONTACT: I can be reached at 206-550-3830. Phone conversations over 10 minutes will begin to incur prorated fees. Treatment summaries or other special document preparation will be prorated at the individual therapy session rate. In the event that I am away from the office for any significant amount of time, I will allow prior notice and provide an alternate contact in my absence. This is a private practice therapy model that does not offer crisis services or after-hours coverage. Please utilize 911 if you experience an emergency. Crisis Clinic: 1-866-427-4747 National Suicide Hotline: 1-800-273-8255 WA Warm Line (peer support): 1-877-500-9276 Trans Lifeline: 1-877-565-8860 Teenlink: 1-866-833-6546 Trevor Project: 1-866-488-7386. [or text START to 678-678] Emergency Support is now consolidated at the number: 988.

CONSENT: I have read this document and had the opportunity to ask questions, been provided contact numbers and complaint information. I understand the confidentiality policy and restrictions. I fully understand and will abide by the cancellation policy. I am able to provide documentation pertaining to any custody/guardianship concerns upon request. By signing I am stating that I am of competent mind and take responsibility for my decision. Where applicable: I am legal guardian of the child mentioned below and have full permission to sign on their behalf for behavioral health services. ( all client packets will include this document with area for date and signature by client, guardian where applicable, and therapist)