Notice of Privacy

Notice Of Privacy Practices

To Our Clients:

The following information is to familiarize you with our policies and practices. If you have any questions, we are pleased to answer them.

CONFIDENTIALITY:

The maintenance of strict confidentiality is essential to the practice of clinical and counseling psychology. Your informed written consent is required for the release of any information about you except in the following circumstances

  1. We are legally obligated to inform the police if we have reason to believe a client is likely to inflict bodily harm on another person.
  2. If we assess a client to be at high risk of suicide or gravely disabled due to a mental illness we are legally obligated to arrange for protective hospitalization.
  3. We are legally obligated to report suspected child abuse to the State Office of Children’s Services (OCS). We are also required by law to report suspected abuse of handicapped or elderly persons.
  4. In certain legal situations, our treatment records may be ordered released by a court of law. Please discuss with us any concerns in this regard.
  5. When an insurance claim is filed for our services the client (or legal guardian) gives their health insurance carrier the right to make inquiries regarding their mental condition. In certain cases, we may be asked to provide details concerning a client’s presenting problem(s) and treatment needs. Insurance companies usually require a signed release from clients in order to pay benefits directly to a health service provider.
  6. If necessary, we may release a client’s name to a collection agency. In these cases, no treatment related content would be disclosed

In releasing confidential information, we will only disclose those details of a case that are legally or clinically necessary.

If you see someone at our facility that you recognize, please respect his or her confidentiality, as you would want him or her to do the same for you.

Consent for Treatment Contract YOUR HEALTH INFORMATION RIGHTS: Your treatment file will be kept for seven years after your last date of service. After that time, it will be destroyed. Although your health record is the physical property of our program, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) you have the right to:

Consent for Treatment Contract

YOUR HEALTH INFORMATION RIGHTS:

Your treatment file will be kept for seven years after your last date of service. After that time, it will be destroyed. Although your health record is the physical property of our program, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) you have the right to:

  • Obtain a paper copy of this notice of information on request.
  • Inspect and receive a copy of your health record (subject to fee).
  • Amend or supplement certain information in your health record.
  • Request communications of your health information by alternative means or at an alternative location.
  • Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

OUR RESPONSIBILITIES:

We are required to:

  • Maintain the privacy of your health information.
  • Provide you with this notice as to our legal duties and privacy practices with respect to the information we collect and maintain about you.
  • Abide by terms of this notice.
  • Notify you if we are unable to agree to a requested restriction.
  • Accommodate reasonable requests you may have to communicate health information by alternative means or at an alternative location.

We reserve the right to change our practices and to make new provisions effective for all protected health information we maintain. Should our information or practices change, we will mail a revised notice to the address you’ve supplied. We will not use or disclose your health information without your written authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization.

FOR MORE INFORMATION OR TO REPORT A PROBLEM:

If you have questions or would like additional information you may speak with our staff. If you believe your privacy rights have been violated, you can file a complaint with any staff member or with the Office for Civil Rights, US Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Office of Civil Rights or us.

COURT TESTIMONY AND REPORTS:

Court testimony, depositions, and written reports to the court will be charged per hour at our normal hourly rate. Travel and waiting time will be included in the calculation of fees. Please discuss with your clinician in advance any court related services you may require.
Consent for Treatment Contract

PHONE CALLS:

During weekends, after hours, and other times when we may be unavailable, we have voice mail and will always return your call within one working day. If you have a crisis and need immediate help after hours or on weekends, please call 911 or the Crisis Clinic at 866-427-4747.

INSPECTION OF RECORDS:

Federal law grants you the right to review any notes, psychological assessment reports, or other documents that are part of your treatment record. If you would like to review these records, please let us know. Your treatment file will be kept for seven years after your last date of service. After that time, it will be destroyed.

WAIVER & RELEASE OF LIABILITY TO ESTABLISH CARE

I understand and agree that my initial assessment does not imply established care; and will only be defined as established care once the assessment has been complete and it has been determined that he/she is able to proficiently provide the appropriate care needed for me at this time.

MISCELLANEOUS:

If the patient is a minor, we ask that a parent or guardian remain close and leave a cell phone number with the clinician.

Please keep us informed of any changes in your address or phone number so we may contact you in case any changes need to be made in scheduling.

A copy of this material is available upon request.