Notice of Privacy Practices/HIPPA Consent
This describes how your information may be used, disclosed and how you can access this information so please read it carefully.
Uses & Disclosures
Information about your treatment, payment and health care operations.
Treatment: If you approve, may disclose your information to your physician or healthcare provider providing treatment to you, or to family or a friend.
Your Authorization: In addition to the use of your health information for treatment or payment you can provide your information to disclose for any purpose. You have the right to request restrictions on disclosure to your Personal Health Information PHI. Pleas know that providing your PHI in legal proceedings will no longer remain confidential.
Required by Law: Disclosure of your health information if required to do so by law or national security activities.
Abuse or Neglect: Mandatory reporting for suspected abuse or neglect.
Appointment Reminders: If requested appointment reminders are via Text.
Patient Rights
Access: You have the right to look at or receive copies of your health record information without limited exception or charge electronically.
Questions and Complaints
If you would like more information about privacy practices or have questions’, please bring up during your assessment or anytime during your time in treatment. If you have any complaints or concerns, you can contact the California Behavioral Science Examiners BBS at the following email or simply reach out by calling me directly.
https://www.bbs.ca.gov
Informed Consent for Treatment
The risks, benefits, side effects and alternatives of treatment as well as the consequences of noncompliance with treatment will be discussed during your assessment. No promises are made about the results of treatment, and by signing this consent understand that you need to provide accurate information about yourself so that you will receive effective treatment.
Termination of Care: Termination of care can occur at any given time and may be initiated by either the patient or the provider. Appropriate referrals can be provided for your ongoing care and treatment.
Confidentiality: Issues of confidentiality are important and legally protected as confidential and privileged however there are limits and exceptions.
- Suspected abuse of a child, elderly or disabled person.
- You present as a danger to yourself or others and if necessary, law enforcement can be notified to provide protection of yourself or warn an intended victim.
- Court order in legal or company litigation [if a request is denied to quash a subpoena regarding your treatment]
- If using insurance, filing documents to your insurance company, audits, case review of your file or appeals.
- In natural disasters where information can be exposed.
- Authorization to share information with other practitioners or agencies [Approved by you].
Payment: I may use and disclose your health informationto your insurance carrier to obtain payment for services provided to you.
Online Communication: I cannot verify that texts, emails and/or company computer systems will exclude 3rd party access. I recommend that for full confidentiality information be shared and confirmed at time of session or a telephone call for an over the phone consult between sessions. That time will be billed as a consult.
Signature And Agreement for Service: My signature shows that I understand and agree with all the above statements, and I give consent for evaluation and treatment and that I have had the opportunity to ask questions about the treatment process.
Note: In order to begin treatment, you must sign this notice.