INFORMED CONSENT AND AGREEMENT FOR CLINICAL SERVICES
Please read the following information carefully. After you have read the Agreement, please sign your name below to accept the terms of this Agreement.
This document (the Agreement) contains important information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice). The Notice explains HIPAA and its application to your personal health information in greater detail. This document also contains important information about psychotherapy, professional services and business policies related to the psychotherapy your therapist delivers. Please read it carefully and ask any questions you might have. By signing this form you indicate that you agree to and understand the psychotherapy process and business policies between you and your therapist. This document represents an agreement between you and your therapist.
A. INFORMED CONSENT.
As a legally consenting individual, you agree to permit the therapist to provide evaluation, treatment, and therapy to yourself, or any individual under your guardianship. You understand that the therapist has the right to terminate evaluation, treatment, or therapy at any time without incurring additional costs.
Psychotherapy can have benefits and risks. As with most other forms of treatments, results cannot be guaranteed.
Participation in therapy can result in a number of benefits to you, including increased insight into your patterns of feeling, thinking, behaving and relating to others; improvement in your H2H Therapy & Consulting, LLC relationships; solutions to specific problems you bring forward in therapy; and improvement in symptoms of distress.
Benefits to therapy require openness on the part of you, the client. When information about your feelings, thoughts, behaviors, relationships, or other difficulties are withheld, it is not possible for the therapist to help you with them or to help you understand how they may be related (or not) to the issue for which you are seeking treatment. Benefits also require consistent attendance in therapy and work both in and outside of therapy sessions.
Since evaluation and/or therapy often involves discussing unpleasant aspects of your life, you may experience difficult emotions. For some symptoms and emotions get better when shared, and for others they may get worse before getting better.
When these feelings come up, it is important to talk to your therapist about them. These feelings may be natural, tolerable, and expected reactions to your work in psychotherapy. Other times it may be necessary or preferable to change the pace of your therapeutic work if the feelings are too uncomfortable. If the treatment is not helping, it is important to talk about other treatment options.
B. EMERGENCY SITUATIONS.
I operate by appointment only and do not provide 24-hour crisis services. If you have a life-threatening crisis, please call 911, a crisis line, or go to a hospital emergency room. You can also contact 211, or 988 for psychological crisis support. If you anticipate needing additional support, please let your therapist know and we can be sure to work together in your next session to create a support plan that meets your needs.
Confidentiality is an incredibly important piece to psychotherapy. Information shared with your therapist will remain confidential and will not be shared with anyone without your written authorization. However, there are circumstances in which I am required to disclose information without either your consent or authorization, including:
● If you are involved in a court proceeding, information pertaining to your evaluation, diagnosis, or treatment is protected by the therapist-patient privilege law. The therapist cannot provide any information without either:
- Your or your personal representative's written authorization
- Receipt of a subpoena with documentation of satisfactory assurances of notice to the client and a certification that no objection was made by the client, or that the time for filing objection has elapsed, and no objection was filed, or all objections filed were resolved by the court, and the disclosures are consistent with the resolution OR
- A court order signed by a judge
● Jessica Soule, LCSW of H2H Therapy & Consulting, LLC may be required to provide information if a government agency is making a request for the information to be used in health oversight activities.
● Jessica Soule, LCSW of H2H Therapy & Consulting, LLC may disclose relevant information regarding a patient in order to defend herself if a patient files a complaint or lawsuit against her.
● If you participate in court ordered therapy and the court requests records or documentation of your participation in services, your therapist will discuss the information being sent to the court with you prior to submitting it.
● In the case of a credit card dispute, your therapist reserves the right to provide the needed and adequate documentation (i.e. your signature on the “Therapy Agreements and Consent” that covers the cancellation policy) to your Bank or Credit Card Company should you dispute a charge that you are financially responsible for. If you have a financial balance, you will be sent a bill to the home address on the intake form unless you make other arrangements.
There are some situations in which your therapist may be legally obligated to take actions in order to protect you or others from harm. At that time, I may have to reveal some information about your treatment, including:
● If your therapist has reasonable cause to suspect that a child under 18 is abused, abandoned or neglected, or if there is reasonable cause to believe that a vulnerable adult is abused, neglected or exploited, the law requires that I file a report with the appropriate government agency.
● If your therapist believes that you present a clear and immediate probability of physical harm to another, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization of the patient.
● Your therapist may be required to seek hospitalization for you or to contact family members or others who help provide protection if I believe that you present a clear and immediate danger to yourself.
Additionally, your confidentiality may be waived in the event your therapist chooses to enlist a collection agency and/or claims court to recover any unpaid balance for which you are responsible. In this case, only information relevant to payment would be released such as dates and types of service, no clinical information would be conveyed.
I sometimes find it helpful to consult with other professionals regarding clients. When doing so, a client’s name and other identifying information is not disclosed. Confidentiality is maintained during these consultations and the client’s identity remains anonymous.
There may be a time where I use an administrative assistant for scheduling, billing, and filing. All administrative staff have been given training about protecting your privacy and have agreed not to release any information without being legally required or with the permission of the client or therapist.
If you sign an authorization to release information form and specify the information you want released, I will release that information to the agency or person you approve unless releasing the information could be harmful to you.
D. CONFIDENTIALITY OF EMAIL, CHAT, CELL PHONE, VIDEO, AND FAX COMMUNICATION.
Communication with your therapist via any online or electronic means (e.g. email, text, video chat) is limited in security and thus your confidentiality may not be guaranteed. In the event of an injury, illness, or other unexpected emergency situation that results in your therapist being unavailable, your basic contact information (name and contact numbers or email) may be provided to a fellow therapist or associated professional. This will allow for your timely notification of appointment cancellations, as well as provide you with an opportunity to obtain further information regarding your continued care.
Considering all of the above exclusions, if it is still appropriate, upon your request, your therapist will release information to any agency/person you specify unless they conclude that releasing such information might be harmful in any way.
Zoom video exchanges, Google Meet video exchanges and Google Workplace email correspondence are secure. By signing this document, you agree to work with online email and video services determined to be suitable by H2H Therapy & Consulting, LLC. If you choose to use your personal email account, please limit the contents to administrative issues (e.g., cancellation, change in contact information, etc.). Remember that unless we are both on landline phones, the conversation is not confidential. Similarly, text messages and fax correspondence are not confidential. If you are working online, your therapist asks that you determine who has access to your computer and electronic information from your location, including family members, co-workers, supervisors, and friends. We advise you to communicate through a computer that you know is safe (i.e. wherein confidentiality can be ensured). Finally, be sure to fully exit all online counseling sessions and emails before leaving your computer.
The therapist should be notified at least 24 hours in advance via email or phone call/voicemail for a session cancellation. If you, the client, cancels your session with less than 24 hours of notice (late cancellation), you will be responsible for the full fee for the missed session. If you are late to a session, the session will not be extended and still end on-time. In this case, you will be responsible for the full fee for the session. If you fail to show up for your scheduled session (missed session/appointment), you will be charged the full fee for the missed session.
F. RIGHT TO DISCONTINUE TREATMENT.
The therapist has the right to discontinue evaluation, treatment, or therapy for any appropriate reason, including but not limited to, repeated lateness and excessive cancellations. In such cases, the patient or the patient’s personal representative agrees to accept full responsibility for pursuing alternate professional services. A letter will be sent informing you or your personal representative that treatment is being discontinued.
G. PROFESSIONAL RECORDS.
You have access to your clinical record, unless such access is determined by the therapist to be harmful to you. If that access is restricted, the client and/or their legal representative will receive written notice of that fact and the reasons for the restriction will be recorded in the therapist’s clinical record. If you are a parent, you understand that you have the right to general information about your child's treatment but may not necessarily have access to the complete record. You agree to provide information to the therapist that will enable her to deliver appropriate care and assistance. It is important for you to know that the therapist is independently providing you with clinical services and is fully responsible for those services.
H. PATIENT RIGHTS.
HIPAA provides you with a number of rights, which briefly include the right to amend the information in your record and to request restrictions as to how you are contacted. Please review the Notice of Privacy Practices carefully.
I. MEDICAL EXAMINER'S OFFICE.
In the event of my death, you hereby release and hold harmless the therapist as the custodian of your Clinical Record from any and all liability resulting from or arising out of the release of your record to the Medical Examiner’s Office pursuant to state law.
J. ELECTRONIC COMMUNICATION AND SOCIAL MEDIA POLICY.
Multiple types of electronic communications are common in our society, and many individuals believe this is the preferred method of communication with others, whether their relationships are social or professional. Many of these common modes of communication, however, put client privacy at risk and can be inconsistent with the law and with the standards of this profession. Consequently, the therapist has prepared this policy to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.
If you have any questions about this policy, please feel free to discuss this with the therapist.
The therapist uses email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. Any email communication or text messages with the therapist should be limited to things like setting and changing appointments, billing matters, and other related issues. If you need to discuss a clinical matter with the therapist, please do not email but rather feel free to discuss it during your next therapy session. Emails will be responded to during business hours only, unless otherwise specified.
Because text messaging is not a secure mode of communication, I do not use text messaging to contact clients or respond regarding treatment. Please discuss with me if you need to use a messaging platform for any reason.
The therapist does not communicate with their clients through social media platforms (e.g., Twitter, Facebook, Instagram, etc). If the therapist discovers that an accidentally established online relationship with the patient exists, they will cancel that relationship. This is because these types of casual social contacts can create significant security risks for the patient.
The therapist participates on various social networks, but not always in professional capacity. If you engage in online forums, there is a possibility that you may encounter the therapist by accident. If that occurs, please discuss it with them during scheduled time together. Please do not try to contact them via social media. The therapist will not respond but rather terminate any online contact no matter how accidental.
The therapist has a professional website that is used for professional reasons to provide information to others about the therapist and their practice. You are welcome to access and review the information that is on that website and, if you have questions about it, it should be discussed during your therapy sessions.
The therapist will not use web searches to gather information about you without your permission. The therapist believes that this violates your privacy rights; however, they understand that you might choose to gather information about the therapist that way. There is an incredible amount of information available about individuals on the internet, much of which may be inaccurate. If you encounter any information about the therapist through web searches, or in any other fashion for that matter, please discuss this with them during scheduled time together so that it can be processed.
Clients may sometimes want to review their healthcare provider's various websites. Unfortunately, mental health professionals cannot respond to potentially inaccurate comments or related errors because of confidentiality restrictions. If you encounter a review of the therapist, please share it in treatment so that it can be discussed. Please do not rate the therapist’s work on any of these websites while in treatment together as it could potentially damage the therapeutic relationship.
Limitations of Online Psychotherapy
Telephone, chat, and video sessions have strengths and limitations compared to sessions provided in a shared physical space. It is important to consider if those limitations may impact your therapeutic progress and if so, select an in-person provider. In some clinical situations, such as crises or suicidal or homicidal thoughts, in-person treatment may be the most appropriate treatment choice.
Online psychotherapy providers, like many in-person providers, do not provide 24-hour crisis services. If a life-threatening crisis should occur, contact a crisis hotline, call 911, or go to a hospital emergency room. Should your therapist determine that you are at risk, they may call local police to assess your safety in person.
Your therapist follows the laws and professional regulations of the state in which the provider is licensed, and the sessions will be considered to take place in the state and country in which the provider is licensed.
K. MINORS & PARENTS.
Emancipated Minors do not need parental consent for mental health care. Their private health information is confidential and cannot be released to anyone without the client’s consent.
Unemancipated Minors must have the consent of their personal representative (e.g., natural or adoptive parents, legal custodians or guardians, or a person acting as the minor’s parent) for non- emergency mental health care. Unless the personal representative agreed in advance to a confidential status between the child and the therapist, they have access to the minor’s record. Confidential status means that a therapist asks a personal representative to step out so that the provider may talk confidentially to the minor client (i.e., the representative agrees to confidential relationship between the child and the provider, and may only know what the conversation was about if the child authorizes it).
It is our company’s policy to require authorization for treatment from all legal guardians of the minor child except under specific situations which may require an affidavit. Furthermore, if consent is revoked by any of the legal guardians or parents, it is our center’s policy to terminate treatment except in emergencies.
L. TERMINATION OF SERVICES.
You are free to end service at any time for any reason, whether or not the therapist considers it advisable. The therapist prefers that you tell him/her when you plan to terminate treatment instead of just not returning and that you schedule one final appointment in order to review your progress and discuss any referrals that might be beneficial to you.
There are a few situations in which the therapist may end service regardless of your wishes:
● If the therapist is convinced that you no longer need service and cannot benefit from continuing.
● If the therapist is convinced that your needs surpass his/her ability to help you, he/she will refer you to a suitable source of help.
● If you do not comply with our mutually developed treatment plan, there is no benefit in continuing service.
● If you do not abide by the policies and procedures of this setting as set forth in our working agreement, including missing appointments or failing to be current in payments.
● If our service relationship becomes compromised, troubled, or deteriorates. In such instances, we will discuss potential issues as part of therapy. If the problems cannot be resolved, it will be necessary to end our service relationship. The therapist will then refer you to another source of service. If you are in crisis, the therapist will make every effort not to end the relationship until the crisis is resolved.
M. TIME OF APPOINTMENTS.
Appointments are scheduled to last 53 minutes. The therapist usually begins at the scheduled time. If the therapist is ever late, they will try to let you know in advance. If the late start is due to the therapist, the session’s duration will still be for a full 53 minutes. If you arrive late for an appointment, we will end the meeting when it was originally scheduled to end. The charge to you for these shortened meetings will be for the full amount; however, you will not be charged for a session if you cannot keep it and let the therapist know at least 24 hours in advance. You will be charged if you fail to keep a scheduled appointment or do not notify the therapist 24 hours ahead of time. Serious immediate emergency conditions will be considered.
In the event that you are called away for an emergency or have a sudden illness or accident, please make every effort to contact, or have someone else contact, the therapist as soon as possible. They will be concerned about you and will want to know your circumstances. The therapist will want to reschedule the appointment if possible. In the event that the therapist is called away for an emergency or has a sudden illness or an accident, the therapist will make every effort to contact you as soon as possible, to apprise you of the circumstances, and to reschedule the appointment.
N. RESPONSIBILITY OF PAYMENT.
You understand that the out-of-pocket fee for service is $100 for a 53-minute therapy session or whatever was agreed upon at the time the appointment was made. Insurance copays and fees may vary depending on your insurance coverage. H2H Therapy & Consulting, LLC currently does not participate with any insurance plans, but is a certified out of network provider for Tricare. A superbill can be provided for out-of-network clients upon request. You understand that there is a full fee charge for appointments that are not canceled with at least 24 hours of notice. You understand this cancellation policy and agree to the terms. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, the therapist has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require disclosure of otherwise confidential information.
O. AUTHORIZATION FOR INSURANCE BENEFITS BILLING.
You hereby authorize the release of any medical or other information necessary to process claims. You also authorize payment of medical benefits to the therapist for the services described in the submitted claims.
P. THE THERAPEUTIC PROCESS.
1. Participating in therapy may have several beneficial consequences, including improving personal relationships and resolving the concerns that led you to therapy. Therapy will seek to meet goals established by all persons involved, usually revolving around a specific complaint(s). Major benefits that may be gained from participating in therapy include: a reduction in distress and a better ability to handle or cope with personal, relational, family, work, and other problems as well as stress; greater understanding of personal and relational goals and values; greater maturity and happiness as an individual and increased relational harmony; and resolving specific concerns brought to therapy. The therapist cannot guarantee an ultimate outcome of therapy.
2. Homework assigned in therapy is an essential aspect of change and the therapist may assign tasks between sessions related to your goals. It is imperative that you commit to work as efficiently as possible. At times, you may feel as if therapy is progressing slower than you anticipated. The therapist and you will work together to identify your therapeutic goals and then periodically, review your progress toward the identified goals.
3. In working to achieve these potential benefits, the therapeutic process requires that actions be made to change and may involve experiencing discomfort in several ways, including through intense, unexpected feelings or relational changes that may not be originally intended. It is important to understand that albeit the collaborative effort of the therapist and patient, there is a possibility that the goals of therapy will not be met. We will review your progress at regular intervals and modify our treatment plan as needed.
R. LENGTH OF THERAPY.
Therapy sessions are typically weekly or biweekly for 53 minutes depending upon the nature of the presenting challenges. It is difficult to initially predict how many sessions will be needed, but the therapist will continuously assess, together with you, how much longer therapy is recommended.
S. TRIAL, COURT ORDERED APPEARANCES, LITIGATION.
Rarely, but on occasion a court will order a therapist to testify, be deposed, or appear in court for a matter relating to your treatment or case. Mental Health Treatment does not include court services. Additional fees will apply if you require therapist involvement in court proceedings. Court fees are not covered by your health insurance and you will be billed directly. Please know if the therapist gets called into court by you or your attorney, you will be charged $150/hour (e.g., travel to and from the courthouse, time in court, waiting for the court hearing, preparation for documents, etc.), with a required minimum fee of $300 paid 24 hours before court proceedings. Reports written for court proceedings will be billed at $120 per hour, with a minimum of 2 hours of work paid in advance. These funds are nonrefundable. A proposed invoice will be drawn up and you will be required to pay prior to the appearance.
Discharged from care
Psychotherapy is best ended with a process of termination and a scheduled final appointment. This will allow you to review therapeutic gains achieved during treatment; develop a plan of action to maintain those gains; identify what other services or activities may still be needed; and to process any emotions that may exist regarding the ending of the therapeutic relationship. If you decide to end therapy without engaging in the process of termination by not scheduling H2H Therapy & Consulting, LLC appointments or by not returning at least two telephone calls, it will be assumed that you are no longer a client of your therapist and you are, therefore, discharged from care.
Both the therapist and the client have the right to end counseling at any time.
Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.) neither you (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the therapy records be requested.
Mediation and Arbitration
All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before and as a precondition of, the initial of arbitration. The mediator shall be a neutral third party chosen by agreement of your therapist and you (the client). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorney’s fees. In the case or arbitration, the arbitrator will determine that sum.
Your signature indicates that you have read this contract in its entirety; that you understand all that it contains; that you agree to abide by its terms; and that you voluntarily consent to treatment. Additionally, your signature below indicates that you understand that I, Jessica Soule, LCSW, am an independent practitioner; therefore, no other entity, platform, or associated providers are not responsible for or involved in your care or treatment unless you directly contracted with that provider.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. OUR RESPONSIBILITIES:
We reserve the right to change this Notice of Privacy Practices and to make any new Notice of Privacy Practices effective for all protected health information that we maintain. Any new Notice of Privacy Practices adopted will be posted at our website and can be made available at your next appointment.
II. WHAT IS "PROTECTED HEALTH INFORMATION" (PHI)?
Protected health information ("PHI") is demographic and individually identifiable health information that will or may identify the patient and relates to the patient's past, present or future physical or mental health or condition and related health care services.
USES AND DISCLOSURES OF INFORMATION
Under federal law, we are permitted to use and disclose personal health information without authorization for treatment, payment and health care operations.
III. WHAT DOES "HEALTH CARE OPERATIONS" INCLUDE?
Health care operations include activities such as communications among health care providers, conducting quality assessment and improvement activities; evaluating the qualifications, competence, and performance of health care professionals; training future health care professionals; other related services that may be a benefit to you such as case management and care coordination; contracting with insurance companies: conducting medical review and auditing services; compiling and analyzing information in anticipation of or for use in legal proceedings; and general administrative and business functions.
IV. HOW IS MEDICAL INFORMATION USED?
We use medical records as a way of recording health information, planning care and treatment and as a tool for routine health care operations. Your insurance company may request information such as procedure and diagnosis information that we are required to submit in order to bill for treatment we provide to the patient. Other health care providers or health plans reviewing your records must follow the same confidentiality laws and rules required of us. Patient records are also a valuable tool used by researchers in finding the best possible treatment for diseases and medical conditions. All researchers must follow the same rules and laws that other health care providers are required to follow to ensure the privacy of patient information. Information that may identify patients will not be released for research purposes to anyone without written authorization from the patient or the patient's parent or legal guardian.
V. HOW MEDICAL INFORMATION MAY BE USED FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS
- Medical information may be used to justify needed patient care services, (i.e., lab tests, prescriptions, treatment protocols, research inclusion criteria).
- We will use medical information to establish a treatment plan. - We may disclose protected health information to another provider for treatment (i.e. referring physicians, specialists and providers, therapists, etc.).
- We may submit claims to your insurance company containing medical information and we may contact their utilization review department to receive pre-certification (prior approval for treatment). We will submit only the minimum amount of information necessary for this purpose.
- We may use the emergency contact information you provided to contact you if the address of record is no longer accurate.
- We may contact you to remind you of your appointment by calling you or mailing a postcard.
- We may contact you to discuss treatment alternatives or other health related benefits that may be of interest.
VI. WHY DO I HAVE TO SIGN A CONSENT FORM?
When you, as the patient or guardian of a patient, sign a consent form, you are giving us permission to use and disclose protected health information for the purposes of treatment, payment and health care operations. This permission does not include psychotherapy notes, psychosocial information, alcoholism and drug abuse treatment records and other privileged categories of information which require a separate authorization. You will need to sign a separate authorization to have protected health information released for any reason other than treatment, payment or healthcare operations.
VII. WHAT ARE PSYCHOTHERAPY NOTES?
Psychotherapy notes are notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are separated from the rest of the patient's medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
VIII. WHAT IS PSYCHOSOCIAL INFORMATION?
Psychosocial information is information provided regarding your social history and counseling or psychiatric services you have received before treatment with me.
IX. WHY DO I HAVE TO SIGN A SEPARATE AUTHORIZATION FORM?
In order to release patient protected health information for any reason other than treatment, payment and health care operations, we must have an authorization signed by the patient or the parent or guardian of the patient that clearly explains how they wish the information to be used and disclosed. The following are some examples of releases of information that require a separate authorization:
- Psychosocial information
- Use of information in scientific and educational publications, presentations and materials.
X. CAN I CHANGE MY MIND AND REVOKE AN AUTHORIZATION?
You may change your mind and revoke an authorization, except (1) to the extent that we have relied on the authorization up to that point, (2) the information is needed to maintain the integrity of the research study, or (3) if the authorization was obtained as a condition of obtaining insurance coverage. All requests to revoke an authorization should be in writing.
XII. WHEN IS MY AUTHORIZATION / CONSENT NOT REQUIRED?
The law requires that some information may be disclosed without your authorization in the following circumstances:
- In case of an emergency
- When there are communication or language barriers
- When required by law
- When there are risks to public health
- To conduct health oversight activities
- To report suspected child abuse or neglect or abuse/neglect to other disabled persons
- To specified government regulatory agencies
- In connection with judicial or administrative proceedings
- For law enforcement purposes
- To coroners, funeral directors, and for organ donation
- In the event of a serious threat to health or safety
XIII. YOUR PRIVACY RIGHTS
The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
1. You have the right to inspect and copy your health information.
This means you may inspect and obtain a copy of your PHI that is contained in a "designated record set" for so long as we maintain the PHI. A designated record set contains medical and billing records and any other records that we use in making decisions about your healthcare. You may not however, inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and certain PHI that is subject to laws that prohibit access to that PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.
2. You have the right to request a restriction of your health information.
This means you may ask us to restrict or limit the medical information we use or disclose for the purposes of treatment, payment or healthcare operations. We are not required to agree to a restriction that you may request. We will notify you if we deny your request. If we do agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by contacting our Privacy Officer.
3. You have the right to request to receive confidential communications by alternative means or at alternative locations.
We will accommodate reasonable requests. We may also condition this accommodation by asking you for an alternative address or other method of contact. We will not request an explanation from you as the basis for the request. Requests must be made in writing to our Privacy Officer.
4. You have the right to request amendments to your health information.
This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with our Privacy Office and we may prepare a rebuttal to your statement and will provide you with a copy of this rebuttal. If you wish to amend your PHI, please contact our Privacy Officer. Requests for amendment must be in writing.
5. You have the right to receive an accounting of disclosures of your health information.
You have the right to request an accounting of certain disclosures of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, to family or friends involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years.
6. You have the right to receive a paper copy of this Notice of Privacy Practices.
XIV. WHAT IF I HAVE A QUESTION / COMPLAINT?
If you have questions regarding your privacy rights, please contact your therapist. If you believe your privacy rights have been violated, you may file a complaint by contacting our office, or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. The address for the Secretary of the Department of Health and Human Services is:
Office of Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center
61 Forsyth St., S.W.
Atlanta, GA 30303-8909
(404) 562-7886 (phone)
(404) 562-7881 (fax)
(404) 331-2867 (TDD)