Notice of Privacy Practices
It is our commitment to safeguard your PHI. The PHI constitutes information created or noted by your counselor that can be used to identify you. It contains data about your past, present, or future, mental health, the provision of services provided to you, or the payment for such treatment. This Notice explains when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, or analyze information within our scope of practice; PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside of our practice. With some exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made.
Please note that I reserve the right to change the terms of this Notice and our privacy policies at any time. Any changes will apply to PHI already on file. Before I make any important changes to my policies, I will change this Notice and post a new copy of it on my website. You may also request a copy of this Notice.
How I will use and disclose your PHI. I may need to use and disclose your PHI. Most of the uses or disclosures will require your prior written authorization; a few, however, will not. Below you will find the different categories of uses and disclosures.
Uses and Disclosures Related to Treatment, Payment, or Reporting that Do Not Require Your Prior Written Consent. While the below circumstances are rare, these are instances where I need to disclose your PHI without written permission:
Mandated Reporting. I am legally required to report instances of suspected child, dependent adult or elder abuse. counselors are also required to break confidentiality when they have determined that a patient presents a serious danger of physical violence to another person or when a patient is dangerous to themselves. In this reporting only relevant PHI will be disclosed in the report.
To Obtain Payment for Treatment. I will always do my best to work with you if you have been affected financially and struggle to make payments for services. In instances where you do not pay your outstanding balance within the time determined and notified I may use and disclose your PHI to bill and collect payment for the treatment and services provided to a bill collection agency to assist in collecting the outstanding balance.
Patient Incapacitation or Emergency. I may also disclose your PHI to others without your consent if you are incapacitated or if an emergency exists and the relevant information is necessary in providing you emergency services..
When disclosure is required by federal or state judicial court order
If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.
Worker’s Compensation. While I will always try to consult with you prior to disclosure, there are certain Worker’s Compensation Laws that require me to disclose PHI.
Health Oversights. When a BBS or other governing agency require disclosure for audit and investigation purposes.
All other Uses and Disclosures Require You to Submit a Signed Release of PHI Form. The following are more common reasons why I may request to disclose your PHI. In each instance you can determine if and what PHI can be disclosed. å
Disclosures to family, friends, or others. I may request to provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment for your counseling services. Retroactive consent may be obtained in emergency situations.
Disclosures to your medical or psychiatric care team. In instances where a health condition may be contributing to your wellbeing, you are seeing a psychiatrist, and/or you are seeing another therapist (ie. couples counseling, family therapy etc.) I may ask to coordinate with your care team in order to provide you with the best treatment possible.
Professional Consultation. There may be times when I, as your psychotherapist, may need to consult with my supervisor or with a colleague or another professional, such as an attorney, concerning issues raised by you in therapy. Confidentiality is not waived during these consultations. By signing this notice, you give me permission, as your psychotherapist, to consult with other professionals as needed to provide professional services to you. This permission may be revoked at any time.
Rights and Process of Seeing or Obtaining Copies of Your PHI. In general, you have the right to see your PHI that I have documented. To do this, you must request it in writing. You will receive a response from us within 30 days of receiving your written request. I may provide a treatment summary instead of copies of the PHI records, this will include a cost for time creating additional documentation at my stated hourly rate. Under certain circumstances, I may reserve the right to deny your request, and will provide you a written notice. I will also explain your right to have the denial reviewed. If you ask for copies of your PHI, I will charge you not more than $0.25 per page.
The Right to Choose How I Send Your PHI to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). I am obliged to agree to your request providing that I can give you the PHI in the format you requested without undue inconvenience.
The Right to Get a List of the Disclosures I Have Made. You are entitled to a list of disclosures of your PHI that I have made (see section 1). The list will not include uses or disclosures to which you have already consented or sent directly to you. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I give you will include disclosures made in the previous seven years unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no cost, unless you make more than one request in the same year, in which case I will charge you a reasonable sum based on a set fee for each additional request.
The Right to Amend Your PHI. If you believe that there is an error in your PHI or that important information has been omitted, it is your right to request that I correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of receipt of your request. I may deny your request, in writing, if I find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d) written by someone else. My denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and our denial be attached to any future disclosures of your PHI. If I approve your request, I will make the change(s) to your PHI. Additionally, I will tell you that the changes have been made, and I will advise all others who need to know about the change(s) to your PHI.
The Right to Get This Notice by Email. You have the right to get this notice by email or paper copy.
Notice of Privacy Practices Acknowledgement:
By signing below I am agreeing that I have read, understood, and agree to the items constrained in this Notice.
Informed Consent for Psychotherapy Acknowledgement:
By signing below, the Client acknowledges that you have reviewed and fully understand the terms and conditions of this Agreement. Client has discussed such terms and conditions with the Therapist, and has had any questions with regard to its terms and conditions answered to the Client’s satisfaction. Client agrees to abide by the terms and conditions of this Agreement and consents to participate in Therapy services with Therapist.