Robin Levick, LMFT #88545

Embodied Relational Psychotherapy, A Marriage and Family Corporation

Effective Date: 7/1/2026

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

I. My Pledge Regarding Health Information

I am committed to protecting your health information. I am required by law to:

  • Keep your Protected Health Information (PHI) private.

  • Give you this notice of my legal duties and privacy practices.

  • Follow the terms of the notice currently in effect.

  • Notify you if there is a breach that compromises the privacy or security of your information.


II. How I May Use and Disclose Health Information Without Your Authorization

For Treatment, Payment, or Health Care Operations: I may use or share your PHI without your written authorization to carry out treatment, payment, or my own health care operations. For example, if you use insurance, I may share information with your health plan in order to be paid for your care. I may also contact you about scheduling, and I may consult my own attorney or accountant about running my practice.


Consultation: I consult regularly with colleagues about my clinical work. When I do so without your written authorization, I do not use your name or any information that would identify you. If I want to consult with a provider involved in your care in a way that requires identifying you, I will ask you to sign a separate authorization first.


Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose information in response to a subpoena or discovery request, but only if efforts have been made to tell you about the request or to obtain an order protecting the information.


I can also share your information without your authorization for the following reasons:

  • Reporting suspected child, elder, or dependent adult abuse.

  • Preventing or reducing a serious threat to anyone's health or safety.

  • Health oversight activities, such as audits or investigations.

  • Law enforcement purposes, such as reporting a crime on my premises.

  • Complying with workers' compensation laws.

  • Public health activities required by law.

  • Responding to a coroner or medical examiner performing duties authorized by law.

  • Other disclosures required or specifically permitted by law.


III. Disclosures You Have the Opportunity to Object To

If you tell me that a family member, partner, friend, or other person is involved in your care or in payment for your care, I may share relevant information with that person unless you object. You can object in whole or in part, at any time. In an emergency, where you are not able to tell me your preference, I will use my judgment about what is in your interest and will discuss it with you afterward.


IV. Special Protections for Substance Use Disorder Records

If I receive or maintain records about substance use disorder treatment, those records get extra protection under federal law (42 CFR Part 2).

  • Consent for Sharing: I generally need your specific written permission to share these records, including for treatment, payment, or health care operations.

  • Legal Proceedings: These records cannot be used against you in civil, criminal, or administrative proceedings without your specific written consent or a special court order.

  • Complaints: You may file a complaint about a violation of these protections with the Secretary of the U.S. Department of Health and Human Services, and you may not be retaliated against for doing so.


V. Uses That Require Your Authorization

Psychotherapy Notes: I do not keep psychotherapy notes as that term is defined in 45 CFR 164.501.

Marketing and Sale: I will not use or share your information for marketing purposes, and I will not sell your information.

Any other use or disclosure of your health information not described in this notice will be made only with your written authorization. You may revoke an authorization in writing at any time, except to the extent that I have already acted in reliance on it.


VI. Your Rights Regarding Your Health Information

  • Request Limits: You can ask me not to use or share certain information for treatment, payment, or health care operations. I am not required to agree to your request.

  • Out-of-Pocket Payments: If you pay for a service in full yourself, you have the right to ask me not to share information about that service with your health insurance plan, and I am required to agree.

  • Confidential Communications: You can ask me to contact you in a specific way, or at a specific address or phone number. I will accommodate reasonable requests and will not ask you why.

  • Access and Copies: You have the right to inspect your record within five working days of a written request, and to receive a copy within fifteen days. If your record is kept electronically, you may request an electronic copy. I may charge a reasonable fee for copies, not to exceed twenty-five cents per page plus reasonable clerical costs.

  • Right to Amend: If you believe there is a mistake in your record, or that something important is missing, you can ask me to correct it or add information. If I deny your request, I will tell you why in writing within sixty days, and you may submit a written statement of disagreement to be kept with the record.

  • List of Disclosures: You can ask for a list of the times I have shared your information for reasons other than treatment, payment, or health care operations, going back up to six years. I will respond within sixty days. The first request in any twelve month period is free.

  • Paper Copy: You have the right to a paper copy of this notice at any time, even if you have received it electronically.


VII. Clients Under Eighteen

A client twelve years of age or older who consents to their own outpatient mental health treatment under California Family Code 6924 holds the privacy rights described in this notice for that treatment. A parent or guardian does not have access to those records without the client's agreement, except where disclosure is otherwise required by law.


VIII. What Happens After I Share Your Information (Redisclosure)

Once I share your health information with another person or organization at your request, such as your insurance company or another provider, I no longer have control over how they handle it. At that point, your information may be shared again by the person who received it, and it may no longer be protected by the same privacy laws that I am required to follow.


IX. Changes to This Notice

I reserve the right to change this notice, and to make the revised notice apply to information I already have as well as information I receive in the future. If I make a material change, I will post the current notice on my website and provide a copy to you on request.


X. Complaints

If you believe your privacy rights have been violated, you may file a complaint with me directly, and I would want to hear it. I am the Privacy Officer for this practice, and my contact information is below. You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, by writing to 200 Independence Avenue SW, Washington, DC 20201, by calling 1-800-368-1019, or through ocrportal.hhs.gov. I will not retaliate against you in any way for filing a complaint.


XI. Contact

Robin Levick, LMFT #88545
582 Market St #1904  San Francisco, CA 94104

415.493.8659
robin@robinlevick.com