I am strongly committed to respecting the basic human rights, worth and dignity of each person receiving services. In addition, you have legal rights which are guaranteed by the constitution, state/federal laws and regulations. You also have responsibilities regarding your treatment. These rights and responsibilities include:

The Right to Confidentiality
The right to confidentiality of all records and communications, as provided by Federal law with a few exceptions:

• If I suspect child or elder abuse is suspected.
• If I suspect you may harm yourself or someone else.
• If I receive a court order.
• If you enter into litigation against me.
• If you have an outstanding bill, I can use a collection agency.
• If the client is a minor, I may discuss aspects of the client’s care with the client’s parents or legal guardians.
• If I seek consultation with another professional about your case.

The Right to Treatment

• The right to have all reasonable requests responded to promptly and adequately.
• The right to ask for, and obtain a copy of all rules and policies which apply to clients.
• The right and responsibility to choose a therapist and mode of treatment that meet your needs.
  The modalities I use include but are not limited to: Internal Family Systems, CBT, Mindfulness, and other Trauma-Informed Practices.
• The right to ask questions about my training, therapeutic approach, and progress of treatment.
• The right to be informed, when treatment begins, of expected results and/or side effects of treatment.
• The right to refuse treatment, unless court ordered.
• The right to life-saving treatment.
• The right to refuse to be a research subject.
• The right to adequate care or to be referred to another provider.
• The right to request the name and specialty of any person responsible for care or coordination of care.
• The right to revoke your authorization, in writing, to release or discuss your medical record except when action has already been taken.

The Right to Informed Consent

• The right and responsibility to participate in developing a treatment plan with your therapist.
• The right to receive and read a copy of your medical record, as long as doing so causes no harm.
• The right to maintain HIV status as confidential unless you provide written consent.
• The right to receive an itemized bill, including third party reimbursement paid toward the bill.

The Right of Protection from Mistreatment

• The right to be treated in a manner which is ethical and free from abuse, discrimination and/or exploitation, meaning no romantic or sexual relationship, and your story will not be turned into a movie, book or TV show.
• The right to know that the therapeutic relationship will not be leveraged in an inappropriate manner or develop into a dual relationship.
• The right to be treated with respect no matter your culture, gender, sexual orientation, sexual preference, ability, and religion.

The Right to File a Complaint
If you are concerned about your clinical care and client rights, please speak with me in session or contact me in writing. You may also file a complaint with your State Department of health and my licensing board.

Client Responsibilities

• To keep your schedule appointments and let me know if you cannot keep it by giving 24 hours’ notice.
• To be as honest and as open as possible.
• To think through any insights or concerns you are addressing between sessions.
• To follow through on treatment recommendations and complete any homework agreed upon during session.
• To have a termination session rather than not keeping your last appointment.
• To call 911 or go to your nearest emergency department if you feel you are in danger of harming yourself and then to inform me.

If you have any questions or concerns about your rights and responsibilities, I invite you to please bring them up in session.

This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.

HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations.  The Notice explains HIPAA and its application to your PHI in greater detail.

The law requires that I obtain your signature acknowledging that I have provided you with this.  If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing this document.  When you sign this document, it will also represent an agreement between us.  You may revoke this Agreement in writing at any time.  That revocation will be binding unless I have taken action otherwise.

OVERVIEW
I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

PROFESSIONAL RECORD-KEEPING: The laws and standards of my profession require that I keep treatment records. You are entitled to view your records unless I believe that seeing them would be emotionally damaging, in which case I can provide a summary of the records instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them, or the summary I provide, with me or with a licensed mental health professional of your choice.

LIMITS ON CONFIDENTIALITY: The law protects the privacy of all communication between a patient and a therapist.  In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA.  There are some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary.  Reasons I may have to release your information without authorization:

A. Certain uses and disclosures relating to treatment, payment, or health care operations do not require your prior written consent. I can use and disclose your PHI without your consent for the following reasons:

1. For treatment: I can disclose your PHI to physicians, psychiatrists, psychologists, or any other licensed health care providers who provide you with health care services or are involved in your care. For example, if you're being treated by a psychiatrist, I can disclose your PHI to your psychiatrist in order to coordinate your care.
2. To facilitate payment for treatment: I can use and disclose your PHI to bill for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company or health plan regarding the health care services that I have provided to you. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process my healthcare claims.
3. For health care operations: I can disclose your PHI to operate my practice. I may provide your PHI to our accountants, attorneys, consultants, and others to make sure I am complying with applicable laws
4. Other disclosures: I may also disclose your PHI to others without your consent in certain situations. For example, your consent isn't required if you need emergency treatment, as long as I try to get your consent after treatment is rendered, or if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so

B. There are additional uses and disclosures that do not require your consent. I can use and disclose your PHI without your consent or authorization for the following reasons:

1. When disclosure is required by federal, state or local law; judicial or administrative proceedings; or, law enforcement: If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them. For example, I may make a disclosure to applicable officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding.
2. Lawsuits and Disputes: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law.  Some circumstances may require that I disclose health information in response to a court or administrative order. If you are involved in a lawsuit, I may also be requested disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. I cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. I If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.
3. For public health activities: For example, I may have to report information about you to the county coroner.
4. For health oversight activities: For example, I may have to provide information to assist the government when it conducts an investigation or inspection of a healthcare provider or organization.
5. For research purposes: In certain circumstances, I may provide PHI in order to conduct medical research.
6. For specific government functions: I may disclose PHI of military personnel and veterans in certain situations. And I may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations.
7. For workers' compensation purposes: If a patient files a worker's compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider.
8. Appointment reminders and health related benefits or services: I may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits I offer.
9. Supervision and/or Consultations: I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
10. To avoid harm: In order to avoid a serious threat to the health or safety of a person or the public, I may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm.

C. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient's treatment:

1. If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the New York State Central Registry.  Once such a report is filed, I may be required to provide additional information.
2. If I know or have reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the New York State Central Registry.  Once such a report is filed, I may be required to provide additional information.
3. If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.

D. Certain uses and disclosures require you to have the opportunity to object. Disclosures to family, friends, or others: I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

E. Other uses and disclosures require your prior written authorization. In any other situation not described in sections A, B, C, and D above, I will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I have not taken any action relying on such authorization) of your PHI by me.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION 
Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a.) For my use in treating you.

b.) For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c.) For my use in defending myself in legal proceedings instituted by you.

d.) For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

e.) Required by law and the use or disclosure is limited to the requirements of such law.

f.) Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g.) Required by a coroner who is performing duties authorized by law.

h.) Required to help avert a serious threat to the health and safety of others.

i.) As a mental health provider, I will not use or disclose your PHI for marketing purposes.

j.) As a mental health provider, I will not sell your PHI in the regular course of my business.

CLIENT RIGHTS & THERAPIST DUTIES

Use and Disclosure of Protected Health Information:

1. For Treatment – I use and disclose your health information internally in the course of your treatment.  If I wish to provide information outside of our practice for your treatment by another health care provider, I will have you sign an authorization for release of information.  Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
2. For Payment – I may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.
3. For Operations – I may use and disclose your health information as part of our internal operations.  For example, this could mean a review of records to assure quality.  I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.

Patient's Rights

1. Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
2. Right to Confidentiality – You have the right to have your health care information protected.  If you pay for a service or health care 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.  I will agree to such unless a law requires us to share that information.
3. Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, I am not required to agree to a restriction you request.
4. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of your PHI by alternative means and at alternative locations.
5. Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of your PHI.  Records must be requested in writing and release of information must be completed.  Furthermore, there is a copying fee charge of $1.00 per page.  Please make your request well in advance and allow 2 weeks to receive the copies.  If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.
6. Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information.  You have to make this request in writing.  You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days.
7. Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email.  If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.
8. Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you.  On your request, I will discuss with you the details of the accounting process.
9. Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action.
10. Right to Choose – You have the right to decide not to receive services with me.  If you wish, I will provide you with names of other qualified professionals.
11. Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued.  I ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services.
12. Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate.  Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you.

Therapist’s Duties: I am required by law to maintain the privacy of your PHI and to provide you with a notice of my legal duties and privacy practices with respect to your PHI.  I reserve the right to change the privacy policies and practices described in this notice.  Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.  If I revise my policies and procedures, I will provide you with a revised notice in office during our session.

COMPLAINTS: If you think that I may have violated your privacy rights, or you disagree with a decision I made about access to your PHI, you may file a complaint with the person listed below. You also may send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. I will take no retaliatory action against you if you file a complaint about my privacy practices.

Who to contact for information about this Notice or to complain about my privacy practices: If you have any questions about this Notice or any complaints about my privacy practices or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me.

 

Jennie Chung, LCSW-R offers clients the opportunity to communicate via email or text message if they choose. However, although every effort is made to ensure confidentiality, transmitting information electronically, by phone, email or text message is not secure. This form provides information about these risks as well as guidelines for communicating via phone, email or text.

POTENTIAL RISKS OF ELECTRONIC COMMUNICATION

• Senders can misaddress/misdial a number, email or text message which can be received by unintended recipients.
• Email and voice or text messages can be recirculated, forwarded or stored in electronic files.
• Backup copies of emails or texts may exist even after the sender or recipient has deleted his/her copy.
• Email can be used to introduce viruses into computer systems.
• The sender may assume that a message was sent or voice messages were received when they were not.
• There is a possibility of misinterpretation of the message due to nonverbal feedback.
• Email and text messages can be lost in transmission.

POTENTIAL COSTS OF TEXT MESSAGING

• Phone users may incur fees for each message they receive.
• Message & data rates may apply to your communications.

HOW WILL ELECTRONIC COMMUNICATION BE USED?
In general, electronic communication with you will only be initiated to discuss non-sensitive issues such as:

• Appointment reminders
• Scheduling, canceling, rescheduling appointments
• Provision of routine forms
• Benefit information

CONSIDERATIONS FOR EMAIL USE

• You are responsible for protecting your own device, your password, or other means of access. Jennie Chung, LCSW-R is not liable for breaches of confidentiality caused by a client or other third party.
• Clients are responsible for taking precautions to protect the confidentiality of messages, for example, password protecting your phone or computer.
• It is the responsibility of the client to inform Jennie Chung, LCSW-R, of changes to your email, phone, address, etc.
• Clients should be mindful that emails and voice/text messages are legally considered part of your medical/clinical record.

PATIENT ACKNOWLEDGEMENT AND AGREEMENT
I acknowledge that I have read and fully understand this consent form. I understand the risks as outlined above and consent to the conditions outlined above. I further waive any and all claims that may arise against Jennie Chung, LCSW-R from the use or misuse of phone calls, text messaging, email and/or any other form of electronic communication.

1. I understand that Jennie Chung, LCSW-R cannot guarantee absolute security/ confidentiality of electronic communications, including phone, email and text messaging.
2. I release and hold harmless Jennie Chung, LCSW-R from any and all expenses, claims, liabilities damages and losses that may result from email or phone/text communication between myself and Jennie Chung, LCSW-R including technical failures beyond reasonable control such as system crashes, power outages, and network overloads.
3. I understand that I may also communicate with Jennie Chung, LCSW-R via my secure patient portal or during my scheduled appointment time, and that phone, email or texting is not a substitute for care that may be provided during a scheduled session. Appointments should be made to discuss any new issues or sensitive information.
4. I understand that either Jennie Chung, LCSW-R or myself may stop using phone, email or texting as a means of communication.
5. I understand that I may revoke this consent at any time by advising Jennie Chung, LCSW-R in writing. My revocation of consent will not affect by ability to obtain future care, nor will it cause the loss of any benefits to which I am otherwise entitled.
6. I understand that failure to comply with the guidelines delineated in this form may result in termination of any phone, email or texting relationship.

I have had the opportunity to ask questions and understand and agree to these policies. I consent and agree to the nature of the services being provided, the risks, the benefits and that I have alternatives to communication via electronic means. I consent that I am voluntarily entering into counseling services with Jennie Chung, LCSW-R, any electronic communication herein.