Notice of Privacy Practices & Telehealth Consent
This notice describes how information about you may be used and disclosed and how you can get access to it. Please review carefully.
1. Your records are used to provide treatment, bill and receive payments, and conduct operations. Examples of these activities include but not limited to review of treatment records to ensure appropriate care, appointment reminder telephone calls, and records review to ensure completeness and quality of care. Use and disclosure of records is limited to the internal used outlined above except required by law or authorized by the patient or legal representation.
2. Federal and State laws require abuse, neglect, domestic violence and threats to be reported to social services or other protective agencies. If such reports are made they will be disclosed to you or your legal representative unless disclosure increases risk of further harm.
3. Disclosed information will be limited to the minimum necessary. You may request an account for any uses or disclosures other than those described in Sections 1 and Sections 2.
4. You, or your legal representative, may request your records to be disclosed to yourself or any other entity. Your request must be made in writing, clearly identify the person authorized to request the release, specify the information you want disclosed, the name and address of the entity you want the information released to, purpose and the expiration date of the authorization. Any authorization provided may be revoked in writing at any time. We have 30 days to respond to a disclosure request and 60 days if the records are stored off site.
5. You may request corrections to your records.
6. A request for disclosure may be denied under the following circumstances: disclosure would likely endanger the life or physical safety of you or another person, requested information references other persons, except another healthcare provider, or if released to a legal representative would likely result in harm.
7. If a request for disclosure is denied for reasons outlined in Section 6, you or your legal representative may request review of the denial. A review will be conducted by another licensed provider appointed by the original reviewer, who was not involved in the original decision to deny access. A review will be concluded within 30 days.
8. You may request that we restrict uses and disclosures outlined in Section 1. However, we are not required to agree to the restrictions. If an agreement is made to restrict use or disclosure, we will be bound by such restriction until revoked by you or your legal representative orally or in writing except when disclosure is required by law or in an emergency. We may also revoke such restrictions but information gathered while required by law or in an emergency. We may also revoke such restrictions but information gathered while the restriction was in place will remain restricted by such an agreement.
9. This agreement may be modified or amended as required by law
10. I understand that the counselors I am seeing are Human Services Board Certified Practitioner’s.
Telehealth Consent
1. I hereby authorize Your Best Life Restoration Counseling to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.
2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.
3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
4. I agree that my session notes on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.