Notice of Privacy Practices

The HIPAA (Health Insurance Portability and Accountability Act) Privacy rule has been put into effect as of April 14, 2003. This rule essentially controls the use and disclosure of what is known as “protected health information.” Implementation of and compliance with this rule is not optional for my practice but is mandated by federal law. I am required to provide you with a copy of the attached information.

• Please read and familiarize yourself with the attached information.
• Your signature is required on the Patient Consent for Use and Disclosure statement, so please sign the consent page as it will remain a permanent part of your medical record.
• If you are a parent or legal guardian of a client, I will need to have a consent form signed by you for the client. By law, there are to be no exceptions.
• Your signature on this page will also indicate that you have received the Notice of Privacy Practices provided to you by this office.

NOTICE OF PRIVACY PRACTICES
This notice describes how health information about you may be used and disclosed, and how you can get access to this information. Please review the attached information carefully. Should you have questions, please ask for assistance.

With your consent, I may use and disclose protected health information about you to carry out treatment, payment and health care operations. Please refer to the Notice of Privacy Practices for a more complete description of such uses and disclosures. You have the right to review the Notice of Privacy Practices prior
to signing this consent. I reserve the right to revise the Notice of Privacy Practices at any time. A revised Notice of Privacy Practice may be obtained by a written request to my office.

With your consent, I may call your home or office and leave a message in reference to any items that may assist the practice in carrying out treatment, practice and health care operations such as appointment reminders, insurance items and any call pertaining to your clinical care. 

With your consent, I may mail to your home any items that assist the practice in carrying out treatment, payment and health care operations.

You have the right to request that I restrict how I use or disclose your personal health information to carry out treatment, payment and health care operations. However, I am not required to agree to your requested restrictions, but if I do, we are bound by our agreement.

By signing this form, you are consenting to my use and disclosure of your protected health information to carry out treatment, payment and health care operations. This consent may be revoked in writing except to the extent that I may have already made disclosures in reliance upon your prior consent.

If you decline to sign this consent, I may decline to provide treatment for you.

MY COMMITMENT TO YOUR PRIVACY
I am committed to protecting health information regarding all care received from other health care providers. I create a record of the care and services you receive in order to provide you with quality care while also being in compliance with mandated legal requirements. This notice is to inform you of the ways in which I may use and disclose identifiable health information regarding you and the care youreceive  here. I also describe your rights and certain obligations I have regarding the use and disclosure or your information.

I am required by law to maintain the confidentiality of health information that identifies you, provide you with this notice of my legal duties and privacy practices concerning your identifiable health information, and to follow the terms of the notice that is currently in effect.

TREATMENT
I may use health information about you to provide you with mental health treatment or services. I may disclose health information about you to your doctors, nurses, technicians, or other personnel who are involved in taking care of you or who are arranging for your care.

PAYMENT
I may use and disclose the health information about you so that the services you receive from me may be billed and payment may be collected from you, an insurance company or third party payor. For example, I may need to provide your health insurer with information regarding services you received here so that your insurer will pay me directly or reimburse you privately for the services provided.

APPOINTMENT REMINDERS
There are times when I may use and disclose your health information to
contact you or remind you of an appointment.

TREATMENT ALTERNATIVES
I may use and disclose your health information to tell you about or recommend
possible treatment options of alternatives.

HEALTH RELATED BENEFITS AND SERVICES
I may use and disclose your health information to tell you about health related benefits or services.

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE
I may release health information about you to a friend or family member who is involved in your health care. I may also give information to someone who helps pay for your care.

RESEARCH
Under certain circumstances, I may use and disclose health information about you for research purposes. All research projects, however, are subject to a special approval process. Before I use or disclose health information for research, the project will have been approved through the necessary approval process. I may, however, disclose health information about you to the people preparing to conduct a research project, for example, to help them find clients with specific health needs as long as the information does not leave my practice. I will always ask you for your permission if the researcher will have access to your name, address or other information that reveals who you are.

AS REQUIRED BY LAW
I will disclose, without your permission, health information about you when required to do so by federal, state or local law enforcement agencies.

SERIOUS THREATS TO HEALTH OR SAFETY
I may use and disclose health information about you when required to prevent a serious threat to your health and safety, or to the health and safety of the public or another person. Any disclosure, however, will only be to someone able to prevent the threat.

MILITARY
If you are a member or enrolling with the armed forces, I may release health information about you as required by military command authorities. I may also release health information about foreign military personnel to the appropriate foreign military authority.

WORKER'S COMPENSATION
I may release health information about you to worker’s compensation or similar programs.

PUBLIC HEALTH RISKS
I may disclose health information about you for public health activities. These activities generally include, but are not limited to, the following:
• To report child abuse or neglect, elder abuse or dependent adult abuse.
• To notify the appropriate government authorities if I believe a client has been the victim of abuse neglect or domestic violence. I will only make this disclosure if you agree to when required orauthorized by law.
• To report harm to property.

HEALTH OVERSIGHT ACTIVITIES
I may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care systems, government programs and compliance with civil rights laws.

LAW ENFORCEMENT
I may release health information if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summon s or similar process.
• Regarding location of a suspect, fugitive, material witness or missing person.
• Regarding a victim of crime if under certain circumstances, I am unable to obtain the person’s consent or agreement.
• Regarding a death that may be the result of criminal conduct.
• Regarding criminal conduct at my office.
• In emergency circumstances to report a crime, the location of the crime or victims, or the identify, description or location of the person who committed the crime.

NATIONAL SECURITY
I may release health information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law. I also may disclose health information about you to authorized federal officials so that they may provide protection to the President of the United States, other authorized persons or foreign heads of state of conduct special investigations.

INSPECTION AND COPIES
You have the right to inspect and obtain a copy of your health information that may be used to make decisions about your care. This typically includes health and filing records, but does not include psychotherapy notes. To inspect and/or obtain a copy of your health information, you must submit your written request to my office. I may charge a fee for the costs involved in copying, mailing or other supplies associated with your request. I may deny your request to inspect and or copy in certain limited circumstances. However, you may request a review of this denial.

Reviews will be conducted by another licensed health care professional chosen by this office.

AMENDMENT
You may ask me to amend your health record if you belief it is incorrect or incomplete, and may request an amendment for as long as the information is kept by and for our practice. To request and amendment, your request must be made in writing and submitted to this office. You must provide me with a reason that supports your requests for amendment. Your failure to submit your request (and the reason supporting your request) in writing will result in denial of your request.

Your requests also may be denied if I am asked to amend information not created by this office, is not part of the health information kept by or for the practice, or is not part of the information which you would be permitted to inspect and copy or that is accurate and complete.

ACCOUNTING OF DISCLOSURES
You have the right to request an accounting of disclosures. This is a list of certain disclosures I have made regarding your health information. To request this list of accounting of disclosures you must submit your request in writing to this office. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free, but there may be a charge for additional lists. I will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

RIGHT TO REQUEST RESTRICTIONS
You have the right to request a restriction regarding the use or disclosure of your health information for treatment, payment or healthcare operations. You also have the right to request that I limit health information disclosed about you to someone who is involved in your care or the payment of your care, such as a family member or friend. I am not required to agree to your request; however, if we do agree, we are bound by our agreement except in case of emergency, when otherwise required by law, or when the information is necessary to provide treatment to you. To request restrictions, you must make your request in writing to this office. In your request, you must state (1) what information you want to limit, (2) whether you want to limit my use, disclosure, or both, and (3) to whom you want the limits to apply.

CONFIDENTIAL COMMUNICATIONS
You have the right to request that I communicate with you about health matters in a certain way or at a certain location. For example, you can ask that I only contact you at work. To request confidential communications, you must make your request in writing to this office. I will not ask you the reason for your request and will accommodate reasonable requests; however, your written request must specify how or where you wish to be contacted.

THIS OFFICE RESERVES THE RIGHT TO REVISE THE PRIVACY POLICY NOTICE
This office reserves the right to change this notice. I reserve the right to make the revised notice effective for health information I already have about you as well as any information I receive in the future. I will post a copy of the current notice in this office. This notice will contain the effective date of revision.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that apply to this office will be made only with your written authorization. If you authorize me to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, I will no longer use or disclose health information about you for the reasons covered by your written authorization. I am unable to “undo” or “take back” any disclosures I have already released with your permission. Please note, I am required to retain records of your care. If you should have any questions regarding this statement, please ask for assistance in explaining any portion(s) that are not clearly understood.

SOCIAL MEDIA
During the course of treatment, all social media interactions will be off limits between me as your therapist and you as my client. This includes not following each other on Facebook, Instagram, Twitter, LinkedIn, etc. All communication will be limited to email correspondence and phone calls only.