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Privacy Policy

This Notice of Privacy Practices (the “Notice”) describes how medical information about you may be used and disclosed and how you can get access to this information. In the event you have given someone medical power of attorney, or you have a legal guardian or representative, that person can make decisions for you regarding your health information and exercise your rights under this notice. We will verify that the individual is legally authorized before we disclose any information to, or take any direction from, the individual. Please review this notice carefully. If you have any questions about the notice, please contact our privacy contact, Mary E. Salcedo, MD at 202-363-1010.

This notice tells you how we may use and disclose your medical and demographic information that may identify you and that relates your past, present future physical or mental health or condition and related health care services(also referred to as protected health information or PHI)to treat you, bill for the care we provide, and operate our practice in a business-like manner. It also explains when we may use or disclose your information to comply with various laws. We are required to abide by the terms of this notice. We may change the terms of this Notice, at any time. The new notice will be effective for all PHI that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

Your PHI may be used and disclosed by your physician or mental health provider, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to receive payment for your health care bills and to support the operation of this practice. The Ross Center will limit its own uses and disclosures of PHI to the minimum amount of information necessary to accomplish the purpose at hand. We will also comply with state law if it is stricter than the requirements stated in this Notice.

Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. We will also disclose PHI to other physicians who may be treating you when we have the necessary permission from you to disclose your PHI. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your PHI will be used, as needed, to obtain payment for your health care services. This may include certain activities your health insurance plan may undertake before it approves or pays for the health care services we recommend and have provided for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, we often are required to provide written medical documentation to support services provided to you.

Healthcare Operations: We may use or disclose, as-needed, your PHI in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI, as necessary,to contact you to remind you of your appointment. We will share your PHI with third party “business associates” that perform various activities(e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your PHI, we will have a written contract that contains terms that will protect the privacy of your PHI in accordance with applicable law.

We may use your name and address to send you a newsletter about our practice and the services we offer. We may also use your PHI to provide you with information about treatment alternatives or other health-related benefits and services that are relevant to your condition. We will, under no circumstances, sell our patient lists to any third party.

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close
friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care.
If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine
that it is in your best interest based on our professional judgment.

We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosure to family or other individuals involved in your health care.

Other Permitted and Required Uses and Disclosures of Protected Health Information for Public Policy Purposes
We may use or disclose your PHI in the following situations:

  • Required By Law: We may use or disclose your PHI to the extent that such use or disclosure is required by law.
  • Public Health: We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information
  • Communicable Diseases: We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
  • Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections
  • Abuse or Neglect: We may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your PHI if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information.
  • Food and Drug Administration: We may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
  • Legal Proceedings: We may disclose PHI about you in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal to the extent such disclosure is expressly authorized. We may also disclose PHI about you in response to a subpoena, discovery request other lawful process., provided appropriate steps have been taken to notify you or to get a protective order the court to safeguard your PHI.
  • Law Enforcement: We may disclose PHI for law enforcement purposes, such as: (1) legal processes and otherwise required by law, (2) pertaining to victims of a crime, (3) suspicion that death has occurred as a result of criminal conduct, (4) in the event that a crime occurs on the premises of the practice, and (5) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.
  • Coroners, Funeral Directors, and Organ Donation: We may disclose PHI to a coroner, medical examiner, or funeral director for identification purposes, as appropriate.
  • Research: We may disclose your PHI to researchers doing studies based on existing medical records or using existing records to plan a study involving patient treatment when their research has been approved by an institutional review board, which has reviewed the research proposal and established protocols to ensure the privacy of your PHI. If you agree to participate in research involving treatment, you will also be asked to sign an authorization to allow the researcher to use PHI gathered in the study.
  • Imminent Threats: Consistent with applicable federal and state laws, we may disclose your PHI, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
  • Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel for activities deemed necessary by appropriate military and security purposes.
  • Workers’ Compensation: We may disclose your PHI as authorized to comply with workers’ compensation laws and other similar legally-established programs.
  • Disclosures to the U.S. Department of Health and Human Services: Under the law, we must make disclosures on request to the Secretary of the Department of Health and Human Services (“HHS”) to help HHS determine whether we are operating in compliance or determine our compliance with federal laws that protect the privacy of your health information.
  • Other uses and disclosures of your PHI will be made only with your written authorization, or as otherwise permitted or required by applicable state or federal law. You may revoke an authorization at any time, in writing, except to the extent that your physician or the practice has taken an action in reliance on the uses or disclosures permitted under that authorization.

We will never share your PHI without your permission in the following scenarios:

  • Marketing purposes
  • Sale of your PHI
  • most sharing of psychotherapy notes.

Inspection: You have the right to inspect and copy your PHI. You may inspect and obtain an electronic or paper copy of PHI about you that is contained in a designated record set for as long as we maintain the PHI. A “designated record set” contains medical and billing records and any other records that your physician and/or the practice uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of litigation, or information governed by certain federal laws pertaining to laboratory testing quality. You may be charged a fee for the copying at the rates prescribed understate law; if no amount is specified under state law, we will charge you a reasonable fee. To obtain access to your medical record, you must submit a written request for such record to the Privacy Officer. We will provide you the copy usually within 30 days of receipt of your request.

Restriction: You have the right to request a restriction of your PHI. You may ask us not to use or disclose any part of your PHI for the purposes oftreatment, payment or healthcare operations. You must submit the request in writing and describe the specific restriction requested and to whom you want the restriction to apply. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. If you ask us not to use or share certain PHI, we are not required to honor your request; we can say “no” if doing so would affect your care. If your physician does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. If you pay for a service or item out of pocket, in full, you can ask us not to share that information, for the purpose of payment or our operations, with your health insurer. We will honor your request unless we are required by law to share that information.

Alternative Means: You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or the specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request.

Amend/Correct: You may have the right to have your physician amend or correct your protected health information. You may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, we will tell you why within 60 days. You have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. We will not delete information from your medical record, but we may make adjustments or note corrections to the record, if so agreed. Please contact our Privacy Contact to determine if you have questions about amending your medical record. We may deny your request for an amendment if we believe the information at issue is accurate and complete or if we did not create the information originally.

Accounting: You have the right to receive a list (an accounting) of the times we have shared your health information going back six (6) years from the date of your request. We will let you know who we disclosed your health information with and why, except for those about treatment, payment or healthcare operations, and certain other disclosures such as any you asked us to make. The right to receive this information may be subject to certain exceptions, restrictions and limitations. We will provide you with one accounting free of charge, upon your request, once every 12 months; a reasonable fee will apply for any additional accounting in a 12-month period. You have the right to obtain a paper copy of this Notice from us at any time.

Please contact our Director, Dr. Salcedo, at 202-363-1010 if you have any questions or concerns about this Notice or
our compliance with it.


  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your
  • We will follow the duties and privacy practices described in this Notice.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time.  

Supportive Parenting for Anxious Childhood Emotions (SPACE) Screening Form

Thank you for your interest in our SPACE-informed parenting group. Our group is designed to work with parents of children whose primary difficulty is anxiety with related avoidance behavior. Please answer the following questions so that we can gain a better understanding of you and your child.

Rx Refill Request

Please be advised that the turnaround time for prescription refill requests is no more than 48 business hours.  This means anything received on Friday will be completed no later than the same time the following Tuesday (assuming that Monday is not a holiday).  If you cannot give us that much time, please call the office as soon as possible and do not use this form

REACH Screening Form

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