Legal Notifications2024-01-05T14:58:02-08:00



Angela lzmirian, Ph.D.
Licensed Psychologist (OR 2876/ WA PY61115665)
lzmirian Counseling, PC

I keep a record of the health care services I provide you. You may ask me to see and copy that record. You may also ask me to correct that record. 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 108 SE 124th Ave, Suite 20, Vancouver, WA 98684.


Your health record contains personal information about you and your health. State and Federal law protects the confidentiality of this information. Protected Health Information (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical and mental health, or condition, and related health care services. If you suspect a violation of these legal protections, you may file a report to the appropriate authorities in accordance with Federal and State regulations.

I am required by law to maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy practices with respect to your PHI. This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to 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 am permitted to Use and Disclose Your PHI

For Treatment. I may use medical and clinical information about you to provide you with treatment services.
For Payment. I may use and disclose medical information about you so that I can receive payment for the treatment services provided to you.
For Healthcare Operations. I may use and disclose your protected PHI for certain purposes in connection with the operation of my professional practice, including supervision and consultation.
Without Your Authorization. State and Federal law also permits me to disclose information about you without your authorization in a limited number of situations, such as with a court order.
With Authorization. I must obtain written authorization from you for other uses and disclosures of your PHI. You may revoke such authorizations in writing in accordance with 45 CFR. 164.508(b)(5).
Incidental Use and Disclosure. I am not required to eliminate every risk of an incidental use or disclosure of your PHI. Specifically, a use or disclosure of your PHI that occurs as a result of, or incident to an otherwise permitted use or disclosure is permitted as long as I have adopted reasonable safeguards to protect your PHI, and the information being shared was limited to the minimum necessary.

Examples of How I May Use and Disclose Your PHI

Listed below are examples of the uses and disclosures that I may make of your PHI. These examples are not meant to be a complete list of all possible disclosures, rather, they are illustrative of the types of uses and disclosures that may be made.
Treatment. Your PHI may be used and disclosed by me for the purpose of providing, coordinating, or managing your health care treatment and any related services. This may include coordination or management of your health care with a third party, consultation or supervision activities with other health care providers, or referral to another provider for health care services.
Payment. I may use your PHI to obtain payment for your health care services. This may include providing information to a third party payor, or, in the case of unpaid fees, submitting your name and amount owed to a collection agency.
Healthcare Operations. I may use or disclose your PHI in order to support the business activities of my professional practice including; disclosures to others for health care education, or to provide planning, quality assurance, peer review, or administrative, legal, financial, or actuarial services to assist in the delivery of health care, provided I have a written contract with the business that prohibits it from re-disclosing your PHI and requires it to safeguard the privacy of your PHI. I may also contact you to remind you of your appointments.

Other Uses and Disclosures That Do Not Require Your Authorization

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.
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.
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 I disclose is limited to only that information which is necessary to make the required mandated report.
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.
Research. I may disclose PHI to researchers if (a) an Institutional Review Board reviews and
approves the research and a waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; and (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations.
Criminal Activity or Threats to Personal Safety. I may disclose your PHI to law enforcement officials if I believe that disclosure of confidential information is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
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.
Law Enforcement Purposes. I may be authorized to disclose your PHI to law enforcement officials for law enforcement purposes under the following circumstances, and subject to specified conditions: as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; to identify or locate a suspect, fugitive, material witness, or missing person; in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; to alert law enforcement of a person’s death, if I suspect that criminal activity caused the death; when I believe that protected health information is evidence of a crime that occurred on my premises; if I
believe that disclosure of confidential information is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public; and 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.
Psychotherapy Notes. If kept as separate records, I must obtain your authorization to use or disclose psychotherapy notes with the following exceptions. I may use the notes for your treatment. I may also use or disclose, without your authorization, the psychotherapy notes for my own training, to defend myself in legal or administrative proceedings initiated by you, as required by the Washington Department of Health, the Oregon Board of Psychology, or the US Department of Health and Human Services to investigate or determine my compliance with applicable regulations, to avoid or minimize an imminent threat to anyone’s health or safety, to a health oversight agency for lawful oversight, for the lawful activities of a coroner or medical examiner, as otherwise required by law, or with a valid
court order.

Uses and Disclosures of PHI With Your Written Authorization

Other uses and disclosures of your PHI will be made only with your written authorization. I will not make any other uses or disclose of your psychotherapy notes, I will not use or disclosure your PHI for marketing purposes, and I will not sell your PHI without your authorization. You may revoke your authorization in writing at any time. Such revocation of authorization will not be effective for actions I may have taken in reliance on your authorization of the use or disclosure.

Your Rights Regarding Your PHI

You have the following rights regarding PHI that I maintain about you. Any requests with respect to these rights must be in writing. A brief description of how you may exercise these rights is included.

Right of Access to Inspect and Copy. You may inspect and obtain a copy of your PHI that is
contained in a designated record set for as long as I maintain the record. A “designated record set” contains medical and billing records and any other records that I use for making decisions about you. Your request must be in writing. 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.

Right to Amend. You may request, in writing, that I amend your PHI that has been included in a designated record set. In certain cases, I may deny your request for an 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 of any such rebuttal.

Right to an Accounting of Disclosures. You may request an accounting of disclosures made for treatment purposes or made as a result of your authorization, for a period of up to six years, excluding disclosures made to you. I may charge you a reasonable fee if you request more than one accounting in any 12-month period. Please contact me if you have questions about accounting of disclosures.

Right to Request Restrictions. You have the right to ask me not to use or disclose any part of your PHI for treatment, payment or health care operations or to family members involved in your care. Your request for restrictions must be in writing and I am not required to agree to such restrictions. Please contact me if you would like to request restrictions on the disclosure of your PHI. You also have the right to restrict certain disclosures of your PHI to your health plan if you pay out of pocket in full for the health care I provide to you.

Right to Request Confidential Communication. You have the right to request to receive
confidential communications from me by alternative means or at an alternative location. I will accommodate reasonable written requests. I may also condition this accommodation by asking you for information regarding how payment will be handled or specification of an alternative address or other method of contact. Please contact me if you would like to make this request.

Right to a Copy of this Notice. You have the right to obtain a copy of this notice from me. Any questions you have about the contents of this document should be directed to me.

Right to Opt Out. You have the right to choose not to receive fundraising communications.
However, I will not contact you for fundraising purposes.

Right to Notice of Breach. You have the right to be notified of any breach of your unsecured PHI.

Contact Information

I act as my own Privacy and Security Officer. If you have any questions about this Notice of Privacy Practices, please contact me. My contact information is:
Angela lzmirian, Ph.D.
108 SE 124th Ave, Suite 20,
Vancouver, WA 98684
(971) 267-2761


If you believe I have violated your privacy rights, you may file a complaint in writing with me, as my own Privacy Officer, as specified above. You also have the right to file a complaint in writing to the Washington Department of Health, the Oregon Board of Psychology, or to the US Secretary of Health and Human Services. I will not retaliate against you in any way for filing a complaint.

Effective Date

Effective date of this notice: January 4, 2023



“Right to Receive a Good Faith Estimate of Expected Charges”
– Under the No Surprises Act

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. A Good Faith Estimate will be available upon scheduling or upon request.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, click here or contact me, Angela Izmirian, Ph.D., at (971) 267-2761.



(OMB Control Number: 0938-1401)

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.



If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.


When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent and give up your protections.

You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
  • Your health plan generally must:
  1. Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  2. Cover emergency services by out-of-network providers.
  3. Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  4. Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact: 1.) Washington State Department of Health (360-236-4501) 2.) Washington State Office of the Insurance Commissioner (1-800-562-6900 or 3.) Oregon Board of Psychology (503-378-4154 or or 4.) Oregon Division of Financial Regulation (

Visit Here for more information about your rights under Federal law.

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