HIPAA Acknowledgment Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. As stated in our notice, the terms of the notice may change. If we change our notice, you may obtain a revised copy by looking on our website or using the above contact information.
By signing below, I the undersigned, hereby attest that I have voluntarily entered into treatment, or give my consent of the minor or person under my legal guardianship mentioned above, at (with) (Amy Roth) Journey Therapy at The Barn, LLC, hereby referred to as the Center. Further, I consent to have treatment provided by a psychiatrist, psychologist, social worker, counselor, or intern in collaboration with his/her supervisor. The rights, risks, and benefits associated with the treatment have been explained to me. I understand that the therapy may be discontinued at any time by either party. The clinic encourages that this decision be discussed with the treating psychotherapist. This will help facilitate a more appropriate plan for discharge.
Recipient's Rights: I certify that I have received the Recipientss' Rights information and certify that I have read and understand its content. I understand that as a recipient of services, I may get more information from the Recipient's Rights Advisor.
Nonvoluntarily Discharged from Treatment: A client may be terminated from the Center nonvoluntarily, if; (A) the client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts at the clinic, and/or (B) the client refuses to comply with stipulated program rules, refuses to comply with treatment recommendations, or does not make payment or payment arrangements in a timely manner. The client will be notified of the nonvoluntary discharge by letter. The client may appeal this decision with the Clinic Director or request to reapply for services at a later date.
Client Notice of Confidentiality: The confidentiality of patient records maintained by the Center is protected by federal and/or state law and regulations. Generally, the Center may not say to a person outside the Center that a patient attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless: (1) the patient consents in writing, (2) the disclosure is allowed by a court order, or (3) the disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation.
Violation of federal and/or state law and regulations by a treatment facility or provider is a crime. Suspected violations may be reported to appropriate authorities. Federal and/or state law and regulations do not protect any information about a crime committed by a patient either at the Center, against any person who works for the program, or about any threat to commit such a crime. Federal law and regulations do not protect any information about suspected child (or vulnerable adult) abuse or neglect, or adult abuse form being reported under federal and/or state law to appropriate state or local authorities. Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. It is the Center's duty to warn any potential victim when a significant threat of harm has been made. In the event of a client's death, the spouse or parents of a deceased client have a right to access their child's or spouse's records. Professional misconduct by a healthcare professional must be reported by other healthcare professionals, in which related client records may be released to substantiate disciplinary concerns. Parents or legal guardians of non emancipated minor clients have the right to access the client's records. When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about the client, not clinical information.
My signature below indicates that I have been given a copy of my rights regarding confidentiality. I permit a copy of this authorization to be used in place of the original. Client data of clinical outcomes may be used for program evaluation purposes, but individual results will not be disclosed to outside sources.
ACKNOWLEDGEMENTS OF RECEIPT OF PRIVACY PRACTICE
By signing this form, you acknowledge receipt of the Notice of Privacy Practices that I have given to you. My Notice of Privacy Practices provides information about how I may use and disclose your protected health information. I encourage you to read it in full.
My Notice of Privacy Practices is subject to change. The most recent version will always be at my website at www.journeysupport.net in the Forms section. If I change my notice, you may obtain a copy of the revised notice from me by contacting me at the phone number above. If you have any questions about my Notice of Privacy Practices, please contact me at the address and/or phone number above.
I acknowledge receipt of the Notice of Privacy Practices of Journey Therapy at The Barn, LLC, Amy Roth MS, NCC, LPC-MH.
As a recipient of services at our facility, we would like to inform you of your rights as a patient. The information contained here explains your rights and the process of complaining if you believe your rights have been violated.
YOUR RIGHTS AS A PATIENT
YOUR RIGHTS TO RECEIVE INFORMATION
OUR ETHICAL OBLIGATIONS
WHAT TO DO IF YOU BELIEVE YOUR RIGHTS HAVE BEEN VIOLATED
If you believe that your patient rights have been violated, contact our Recipient's Rights Adviser or Clinic Director.