Confidentiality and HIPAA Consent

Confidentiality and HIPAA Consent

Temenos Center of Integrative Psychology - A DBA of The Family Guidance and Therapy Center (Tax ID: 27-3179020)
Client Name*

First NameLast Name
Use and Disclosure of Protected Health Information (PHI)
Your privacy is a top priority at Temenos Center of Integrative Psychology. This consent outlines how your Protected Health Information (PHI) may be used and disclosed, and your rights regarding this information, as required under the Health Insurance Portability and Accountability Act (HIPAA).

1. How We May Use and Disclose Your PHI
For Treatment
We may use or share your PHI to provide, coordinate, or manage your treatment. For example:
- Sharing information with other healthcare providers involved in your care, such as psychiatrists, medical doctors, or other therapists, but only with your written consent.
For Payment

We may use or disclose your PHI to bill and collect payment for the services we provide. For example:
- Submitting claims to your insurance company for reimbursement.
For Healthcare Operations
We may use your PHI for internal administrative purposes, including quality assessment and staff training.

As Required by Law
We may disclose your PHI when required by federal, state, or local laws. For example:
- Reporting abuse, neglect, or exploitation of a child, elder, or dependent adult.
To Protect Your Safety or Others’
If there is a risk of harm to yourself or others, we may disclose your PHI to prevent harm.
Client Confirmation*

I understand and consent to the use and disclosure of my PHI for the purposes outlined above.
Client Initials*

3. Limits to Confidentiality
Your information may be disclosed without your consent in the following circumstances:
- If there is a risk of harm to yourself or others.
- If abuse or neglect of a child, elder, or dependent adult is suspected.
- If your records are subpoenaed by a court of law.
- If you use your mental health as part of a legal defense.
Client Confirmation*

I understand the limits to confidentiality.
Client Initials*

4. Reporting Complaints
If you believe your privacy rights have been violated, you may file a complaint with the following entities:

Temenos Center of Integrative Psychology

For Medical Doctors or Psychiatrists:
Medical Board of California
Website: https://www.mbc.ca.gov/

For Psychologists:
California Board of Psychology
Website: https://www.psychology.ca.gov/

For Licensed Marriage and Family Therapists (LMFTs), Licensed Clinical Social Workers (LCSWs), or Licensed Professional Clinical Counselors (LPCCs):
California Board of Behavioral Sciences
Website: https://www.bbs.ca.gov/
Client Confirmation*

I understand my rights to file a complaint if I believe my privacy has been violated.
Client Initials*

5. Electronic Communication Consent
Risks of Electronic Communication

I understand that email, text, and fax communications may not be fully secure and could potentially be accessed by unauthorized individuals.

Purpose of Communication

I consent to use email or text for scheduling, administrative tasks, and general communication only. Clinical information should not be shared electronically.
Client Confirmation*

I consent to electronic communication and understand the associated risks.
Client Initials*

6. Acknowledgement & Consent
Client Confirmation*

I have read and understand the Confidentiality and HIPAA Consent document.
Client Confirmation*

I agree to the use and disclosure of my PHI as outlined above.
Client Signature

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Use and Disclosure of Protected Health Information (PHI)