If you have any questions about this notice, please contact administrative office at:

Valley Mental Health
821 Saginaw Street South
Salem, OR 97302
Phone (503) 589-4046


This notice describes the privacy practices followed by us, and the office personnel who manage our practice at the above address.


This notice applies to the information and records we have about your health, health status, and the counseling and care services you have received through Valley Mental Health. Your health information may include information created and received by your therapist, it may be in the form of written or electronic records or spoken words, and may include information about your health history, health status, symptoms, counseling, evaluations, test results, prescriptions, diagnoses, treatments, procedures, and related billing activity and/or similar types of health-related information.

We are required by law to give you this notice. It will tell you about the ways in which we may use  and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.


We may use and disclose health information for the following purposes:

  • For Treatment. With your written consent we may release information to your primary care physician and /or other treating physicians, therapists, counselors, care givers, office staff or other personnel who are involved in taking care of you and your health.For example, your doctor may be treating you for a health condition and may need to know if you have issues or problems that could complicate your treatment. The doctor may use this information to decide what treatment is best for you. We may need to confer with your doctor or another clinician in the field of our practice to assist us in a choice of treatment that would be best for you.Different personnel may share information about you and disclose information to people who do not work in your therapist’s office to coordinate your care, such as scheduling appointments and tests. Family members and other health care providers may be part of your medical care and may require information about you that we have.
  • For payment. We may use and disclose health information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party.For example, we may need to give your health plan information about a service you received so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a treatment you are going to receive to  obtain prior approval, or to determine whether your plan will pay for the treatment.
  • For Health Care Operations. We may use and disclose health information about you to make sure that you and our other clients receive quality care. For example, we may use your health information to evaluate the performance of the office personnel who are caring for you. We may also use health information about all or many of our clients to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective.We may also disclose your health information to health plans that provide you insurance coverage and other health care providers that care for you. Our disclosures of your health information to plans and other providers may be for helping these plans and providers provide or improve care, reduce cost, coordinate and manage health care and services, train staff and comply with the law.
  • Appointment Reminders. Office personnel may contact you by phone as a reminder that you have an appointment for counseling. Please specify to office personnel what phone numbers they may use to remind you of appointments. Please notify us if you do not wish to be contacted for appointment reminders.
  • Treatment Alternatives. We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.
  • Health-Related Products and Services. We may tell you about health-related products or services that may be of interest to you.


We may use or disclose health information about you for the following purposes, subject to all applicable legal requirements and limitations:

To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Required by Law. We will disclose health information about you when required to do so by federal, state or local law.

Military, Veterans, National Security and Intelligence. If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose health information about you for public health reasons to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.

Health Oversight Activities. We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.

Law Enforcement. We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

Information Not Personally Identifiable. We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

Family and Friends. We may disclose health information about you to your family members or friends if we obtain your verbal agreement along with your written authorization to do so. We will give you an opportunity to object to such a disclosure and request you state this in writing. We may also disclose information to your family or friends if we can infer from circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to limited disclosure of information to your spouse when you bring your spouse with you to a counseling session and have not requested in writing that any form of disclosures cannot be made.

In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. For example, we may inform the person who accompanied you to the emergency room that you suffered a heart attack and provide updates on your progress and prognosis. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf.


We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

We will need specific, written authorization from you to disclose certain types of specially-protected information such as HIV, substance abuse, mental health, and genetic testing information.


You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy your health information, such as medical and billing records, that we keep and use to make decisions about your care. You must submit a written request to your therapist or our administrative office to set up an appointment to inspect and/or copy records of your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies.

We may deny your request to inspect and/or copy records in certain limited circumstances. If you are denied copies of or access to information that we keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our denial reviewed, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.

Right to Amend. If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment if your therapists keep the information.

To request an amendment, complete and submit a MEDICAL RECORD AMENDMENT/CORRECTION FORM to your therapist or Valley Mental Health, 821 Saginaw Street South, Salem, Or 97302.

We may deny your request for an amendment if your request is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

  • That your therapists did not create, unless the person or entity that created the information is no longer available to make the amendment
  • Is not part of the information that we keep
  • You would not be permitted to inspect and copy
  • Is accurate and complete

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.”  This is a list of  the disclosures we have made of information about you for purposes other than treatment, payment, health care operations, and a limited number of special circumstances involving national security, correctional institutions and law enforcement. The list will also exclude any disclosures we have made based on your written authorization.

To obtain this list, you must submit your request in writing to your therapist or Valley Mental Health, 821 Saginaw Street South, Salem, Or 97302.

It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate 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, we may charge you for the costs of providing the list. We 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.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a hospitalization you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information  is needed to provide you emergency treatment or we are required by law to use or disclose the information.

To request restrictions, you may complete and submit the REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF MEDICAL INFORMATION to your therapist or to our administrative office at Valley Mental Health, 821 Saginaw St South Salem, OR 97302.

Right to Request Confidential Communications. You have the right to request that we communicate with you about matters in a certain way or at a certain location. For example, you can ask that we only contact you at work by phone or by mail.

To request confidential communications, you may complete and submit the REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF MEDICAL INFORMATION AND/OR CONFIDENTIAL

COMMUNICATION to your therapist or office personnel of Valley Mental Health. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask your therapist or our office personnel to give you a copy of this notice at any time.


We reserve the right to change this notice, and to make the revised or changed notice effective from information we already have about you as well as any information we receive in the future. We will post the current notice in the offices for Valley Mental Health clinicians with the effective date in the top right-hand corner. You are entitled to a copy of the notice currently in effect.


If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services. To file a complaint with our administrative office, please submit a grievance through our Feedback form. You can also request a feedback form by phone or in person at:

Valley Mental Health
821 Saginaw Street South
Salem, OR 97302
Phone (503) 589-4046