I am aware that I may stop my treatment with this therapist at any time. I understand that in some circumstances there may be adverse consequences for me if I choose to stop treatment. For example, if my treatment has been court-ordered, I will have to answer to the court. I understand that my therapist will help me transfer to another therapist if I so choose.
Notice of Privacy Practices
This notice describes how you can access your personal medical information and how we may use and disclose it to provide you with services. Please review it carefully. If you have any questions about this notice, or the practices it describes, please discuss them with your therapist, or contact our Privacy Coordinator, at (603)228-7300.
Our Commitment to Privacy The therapists at Capital Valley Counseling Associates, Inc. (CVCA) are committed to insuring the privacy and confidentiality of the Personally Identifiable Protected Heath Information (PHI) that is created in the course of your treatment. Confidence in the privacy of the sensitive information that clients share with us promotes partnership, honesty, and open dialogue, and facilitates treatment success. The therapists at CVCA take steps to assure that only those individuals who have a legitimate need to access your health information may do so. All CVCA staff and consultants are required to follow the policies contained in this notice. CVCA is required by law to maintain the privacy of your personally identifying health information. Any revision of the law or of the policies contained herein will effect the health information already contained in the record, as well as any information we receive in the future. Any revisions of this notice will be posted in our offices and will be made available for you upon request.
How We Will Use and Disclose Your Health Information The following describes in general the different ways we may use or disclose your health information.
• Treatment: We will use and disclose your health information to provide and coordinate your treatment. CVCA may, attimes, disclose your health information among members of its staff in order to carry out professional consultation so as toensure quality treatment and, if necessary, in order to provide crisis services. For example, if you have called in crisis andyour therapist is not available to take your call, another therapist may need to assist you and access your record.
• Payment: We may use or disclose your health information so that the services you receive are billed to, and payment iscollected from, you, your health plan, or another third party. For example, we may need to disclose health information toyour health plan to obtain authorization for additional visits with your therapist.
• Operations: We may use and disclose health information about you as is necessary to run our organization and makesure that clients receive quality care. For example, we may use and disclose information in the contexts of individual orgroup supervision of staff.
• Quality Assurance: We may use and disclose health information within our staff as necessary to review the quality ofthe records the therapists maintain and the clinical quality of the services provided. For example, your therapists record ofyour treatment may be reviewed by other CVCA staff for accuracy, completeness, and clinical appropriateness.
• Business Associates: We may use and disclose your information to companies and professionals such as ouraccountants, bookkeeper, or attorneys that assist us in running our operations. Contracts with these associates assure thatthe privacy of your health information is protected.
• Individuals Involved in Your Care: We may provide health information about you to someone whom you haveidentified as a caregiver or emergency contact. In an emergency, we may use and disclose your health information tonotify a family member or other person responsible for your care of your location, general condition, or death. We mayalso use or disclose your health information to an entity assisting in disaster relief to inform you family about yourcondition.
• Disclosure Required by Law: We will disclose health information about you when required to do so by federal, state, orlocal law such as a court order or search warrant, or a report of abuse, neglect, or exploitation.
• Averting a Serious Threat to your Health or Safety: We may use or disclose information about you when necessary toprevent a serious threat to your health or safety or to the health or safety of others.• Public Health Activities: We may disclose health information about you as necessary for public health activities. Forexample, we may be required by law to make a report to public health authorities to prevent or control a disease.
• Health Oversight Activities: We may disclose health information about you to a state or federal health oversight agencyfor monitoring, licensing, auditing, inspection, or investigation activities which are authorized by law.
*Law Enforcement Activities: We may disclose health information to a law enforcement official for law enforcement purposes when the information is needed to identify or locate a missing person, to report a death that may be the result of criminal conduct, or to report criminal conduct occurring on our premises.
• Medical Examiners or Funeral Directors: We may provide health information about clients to assist in identifying deceased persons and to determine the cause of death in certain circumstances. We may also disclose health information about our clients to funeral directors as necessary to carry out their duties.
• National Security: We may provide health information about you to authorized federal officials for intelligence andother national security activities authorized by federal law. We may also disclose health information about you toauthorized federal officials so they may conduct special investigations or protect the President or other authorized persons.
• Workers Compensation: We may disclose health information about you to comply with the state’s Workers’Compensation Law.
• Other Uses You Authorize: Uses and disclosures not described above will generally only be made with your written permission, called an “authorization.” You have the right to revoke your authorization at any time. If you revoke your authorization, we will not make any further uses or disclosures of your health information under that authorization, exceptto the extent that we have already taken an action you previously authorized
Your Rights
- Right to Read and Copy: You may read or copy your health information including clinical and billing records andrecords from other providers included in CVCA’s records. You may submit your request to your therapist or the PrivacyCoordinator.
- Right to Request Amendment: For as long as CVCA keeps records about you, you have the right to ask us to amendany health information used to make decisions about your treatment. A request for amendment must be made in writing to your therapist or to the Privacy Coordinator indicating what information you believe to be inaccurate and why. If your request is granted, we will annotate the heath information in question. Under no circumstances will we remove or destroy original documents in your clinical record. We may deny your request if you ask us to amend health information that was not created by CVCA, that is not part of what we must maintain to make decisions about your care, that is not part of the information that you would be permitted to inspect of copy, or that is already accurate and complete.
- Right to an Accounting: You have the right to request that we provide an accounting or list of disclosures we have made after April 14, 2003, excluding disclosures that you authorized or which were for treatment, payment, or healthcare operations. You may submit your request in writing to your therapist or to the Privacy Coordinator.
- Right to Request Restrictions: You have the right to request a restriction on the health care information we use or disclose about you for treatment, payment, or health care operations. You may also ask that any part or all of your health information not be disclosed to family or friends who may be involved in your care. You must request these restrictions in writing. We are not required to agree to a restriction that you may request. If we do agree, we will honor your request unless the restricted health information is needed to provide you with emergency treatment.
- Right to Alternative or Confidential Communications: We will normally communicate with you in person, by phone,or by first class mail. We will accommodate all reasonable requests that we communicate with you only in a certain location or with a certain method. You may request such manner of communication in writing.
- Right to Paper Copy of this Notice: You can obtain a paper copy of this Notice of Privacy Practices at any time fromyour therapist or the Privacy Coordinator.
- Confidentiality of Substance Abuse Records: For individuals who have received treatment for substance abuse, theconfidentiality of such treatment is protected by federal law and regulations.
- Retention of Protected Health Information: CVCA retains client records for 7 years following the termination of services. Retained records may be kept in their original format or may be transferred and stored on electronic media. Following the 7 year period, CVCA may absolutely destroy all files, notes, evaluations, and other client data without further notice to the client.
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Questions, Concerns, or Complaints If you have a question or believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services.
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Privacy Coordinator, CVCA, LLC, 8 Centre Street, Suite 2, Concord, NH, 03301.
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Secretary, HHS, Office of Civil Rights, 200 Independence Ave. SW, Rm. 515 F HHH Bldg. Washington, DC 20201
Clients’ Rights
Confidentiality
All communication between therapist and client is held in strictest confidence unless:
- The client authorizes release of information to a specific person or treatment facility.
- The therapist is ordered by a court to release information.
- The client is believed to be a danger to self or others (e.g. actively planning suicide, homicide, orother damage to a person or to property).
- Abuse/neglect of a child, incapacitated adult, or elder is suspected. In 3 and 4, the therapist is required by law to inform legal authorities and/or potential victims.
- If a client chooses to use his/her insurance, the insurance carrier is legally entitled to receive any and all records at its discretion. In order to bill and receive payment, we are required to provide a diagnosis and often to report a treatment plan, and progress toward stated goals.
- The therapists at Capital Valley Counseling meet regularly for peer supervision and occasionally seek outside supervision. Any information shared in those meetings is subject to the same rules of confidentiality as in any therapy session.
- In treatment of a minor, parents or legal guardians may have the right to review all records. This can often be counterproductive to treatment. Our policy is to discuss this with the parents and their children at intake and determine how such information will be shared.
Emergency Coverage
Clinicians at Capital Valley Counseling Associates, LLC. provide outpatient psychotherapy services. No face-to-face emergency services are offered after hours. Crisis related phone calls will generally be responded to within sixty minutes, either by your therapist or the on-call clinician. If you are experiencing a potentially life-threatening mental health crisis, you will need to contact the emergency service of your local community mental health center or proceed to the nearest hospital emergency room.
Your Relationship with Your Therapist
All members of our staff adhere to the code of ethics of their profession. Dual relationships (for example business, social, romantic and/or sexual) are ethical violations. Sexual contact between a psychotherapist and a client is never appropriate. If a client has a problem with his/her therapist which cannot be resolved with the therapist, the client may request a consultation with the current President or Vice President of Capital Valley Counseling and/or may choose to end therapy. If requested, the client’s therapist or the President or Vice President will offer appropriate referrals to other therapists. Unresolved complaints may also be addressed to the appropriate professional organization or to the New Hampshire Board of Mental Health Practice, 105 Pleasant Street,Concord, NH 03301.
I acknowledge that I have read, understand and am in agreement with the above.