Welcome to my practice. I appreciate your giving me the opportunity to be of help to you. This handout answers questions that clients often ask about therapy. I believe our work will be most helpful to you when you have a clear idea of what we are trying to do.
This information handout talks about the following:
· What the risks and benefits of therapy are.
· What the goals of therapy are, and what my methods of treatment are like.
· How long therapy might take.
· How much my services cost, and how I handle money matters.
· Other important areas of our relationship.
· After you read this information handout, we can talk in person about how these issues apply to you.
This handout is yours to keep. Please read all of it. Mark any parts that are not clear to you. Write down any questions you have, and we will discuss them at our next meeting. When you have read and fully understood this handout, I will ask you to sign it at the end. I will sign it as well and make a copy, so we each have one.
My counseling style is integrative. I believe in modifying the techniques that best serves you and your family strength. I incorporate family therapy as much as possible in my treatment. I usually take notes during our meetings. You may find it useful to take your own notes, and also to take notes outside the office.
By the end of our first or second session:
I will tell you how I see your case at this point and how I think we should proceed. I view therapy as a partnership between us. You define the problem areas to be worked on; I use some special knowledge to help you make the changes you want to make. Counseling is not like visiting a medical doctor. It requires your very active involvement. We will development a treatment plan together to help you meet your identified goals. This is one of the ways you are an active partner in therapy. I encourage you to plan our work together. In your treatment plan we will collaborate together on the areas to work on, your goals, the methods that will be used, time and money commitments you will make, and discuss other relevant issues. I expect us to agree on a plan that we will both work hard to follow. From time to time we will look together at your progress and goals. If we think we need to, we can then change your treatment plan, its goals, or its methods.
An important part of your therapy will be practicing new skills that you will learn in our sessions. I will ask you to practice outside our meetings, and we will work together to set up homework assignments for you. I might ask you to do exercises, keep records, and read to deepen your learning. You will probably have to work on relationships in your life and make long-term efforts to get the best results. These are important parts of personal change. Change will sometimes be easy and quick, but more often it will be slow and frustrating, and you will need to keep trying. There are no instant, painless cures and no “magic pills.” However, you can learn new ways of looking at your problems that will be very helpful for changing your feelings and reactions.
Most of my clients see me once a week for 3 to 4 months. After that, we meet less often for several more months. Therapy then usually comes to an end. This time frame may vary and be shorter or longer, depending on your particular needs. The process of ending therapy, called “termination,” can be a very valuable part of our work. Stopping therapy should not be done casually, although either of us may decide to end it if we believe it is in your best interest. If you wish to stop therapy at any time, or if I decide to terminate therapy with you, I ask that you agree now to meet then for at least one more session to review our work together. We will review your goals, the work we have done, any future work that needs to be done, and your choices. If you would like to take a “time out” from therapy to try working on your issues alone, we should discuss this. We can often make such a “time out” more helpful to you. If you and I do not have contact for 90 days, I will proceed to close out your case.
The Benefits and Risks of Therapy
As with any powerful treatment, there are some risks as well as many possible benefits with therapy. You should think about both the benefits and risks when making any treatment decisions. For example, in therapy, there is a risk that clients will, for a time, have uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These feelings or memories may bother a client at work or in school. In addition, some people in the community may mistakenly view anyone in therapy as weak, or perhaps as seriously disturbed or even dangerous. Also, clients in therapy may have problems with people important to them. Family secrets may be told. Therapy may disrupt a marital relationship and sometimes may even lead to a divorce. Sometimes, too, a client’s problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you.
While you consider these risks, you should know also that the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or their problems are solved. The clients’ relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions—as persons, in their close relationships, in their work or schooling, and in the ability to enjoy their lives. I do not take on clients I do not think I can help. Therefore, I will enter our relationship with optimism about your progress.
If you could benefit from a treatment I cannot provide I will help you to get it. You have a right to ask me about such other treatments, their risks, and their benefits. Based on what I learn about your problems I may recommend a medical exam or the use of medication. If I do this I will fully discuss my reasons with you, so that you can decide what is best. If you are treated by another professional I will coordinate my services with them and with your own medical doctor since I cannot perform medical exams nor can I prescribe medications.
If for some reason treatment is not going well I might suggest you see another therapist or another professional for an evaluation. As a responsible person and ethical therapist, I cannot continue to treat you if I believe that my treatment is not working for you. If you wish for another professional’s opinion at any time, or wish to talk with another therapist, I will help you find a qualified person and will, with your permission, provide him or her with the information that I have about you.
What to Expect from Our Relationship
As a professional I will use my best knowledge and skills to help you. This includes following the standards of the Ohio Counselor, Social Worker, and Marriage and Family Therapy Board, or CSWMFT Board. In your best interests, the CSWMFT Board puts limits on the relationship between a therapist and a client, and I will abide by these. Let me explain in general these limits so you will not think they are my personal responses to you.
First, I am licensed and trained to practice counseling—not law, medicine, finance, or any other profession. I am not able to give you good advice from these other professional viewpoints.
Second, state laws and the rules of the CSWMFT Board require me to keep what you tell me confidential (that is, just between us). You can trust me not to tell anyone else what you tell me, except in certain limited situations. I explain what those are in the “About Confidentiality” section of this information handout and in my Notice of Privacy Practices form. Here I want to explain that I do not reveal who my clients are.
This is part of my effort to maintain your privacy. If we meet on the street or socially I may not say hello or talk to you very much. My behavior will not be a personal reaction to you, but a way to maintain the confidentiality of our relationship.
Third, in your best interest, and following the CSWMFT standards, I can only be your therapist. I cannot have any other role in your life. I cannot, now or even later, depending on the circumstances, be a close friend to or socialize with any of my clients. I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. I cannot have a business relationship with any of my clients, other than the therapy relationship, at least for several years after therapy ends.
If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide evaluations or expert testimony making recommendations on custody, visitation, or what is in the best interest of the child(ren) in court. You should hire a different, independent, mental health professional for any evaluations or testimony like that. This position is based on three reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first; and (3), I am prohibited from providing such testimony by CSWMFT Board rules.
I will treat with great care all the information you share with me. It is your legal right that our sessions and my records about you be kept private. That is why I ask you to sign a “release-of-records” form before I can talk about you or send my records about you to anyone else in most instances. In general, I will tell no one what you tell me. I will not even reveal that you are receiving treatment from me. In all but a few rare situations, your confidentiality (that is, our privacy) is protected by federal and state laws and by the rules of my profession. Here are the most common cases in which confidentiality is not protected:
1. If you were sent to me by a court or an employer for evaluation or treatment, the court or employer expects a report from me. If this is your situation, please talk with me before you tell me anything you do not want the court or your employer to know. You have a right to tell me only what you are comfortable with telling, but once you tell me something I may have to reveal that information to the court or employer.
2. Are you suing someone or being sued? Are you being charged with a crime? If so, and you tell the court that you are seeing me, I may then be ordered to show the court my records. And I may have the obligation and the right to report any felony that you are involved with and tell me about to the police. Please consult your lawyer about these issues.
3. If you make a serious threat to harm yourself or another person, the law requires me to try to protect you or that other person. This usually means telling others about the threat by informing the police or taking other steps to protect you or the other person. I cannot promise never to tell others about threats you make.
4. If I believe a child, a developmentally disabled person, or an elderly adult has been or will be abused or neglected, I am legally required to report this to the appropriate authorities.
There are two situations in which I might talk about part of your case with another therapist. I ask now for your understanding and agreement to let me do so in these two situations. By signing this form you are providing consent for me to share information in this way.
First, when I am away from the office for a few days, I have a trusted fellow therapist “cover” for me. This therapist will be available to you in emergencies. Therefore, he or she may need to know about you. Of course, this therapist is bound by the same laws and rules as I am to protect your confidentiality.
Second, I sometimes consult other therapists or other professionals about my clients. This helps me in giving high-quality treatment. These persons are also required to keep your information private. Your name will never be given to them, some information may be changed or omitted, and they will be told only as much as they need to know to understand your situation.
Except for situations like those I have described above, my office staff and I will always maintain your privacy, except as listed in this Handout and in my Notice of Privacy Practices form. I also ask you not to disclose the name or identity of any other client being seen in this office.
My office staff makes every effort to keep the names and records of clients private. My staff and I will try never to use your name on the telephone if clients in the office can overhear it. All staff members who see your records have been trained in how to keep records confidential and have agreed to keep your information confidential.
It is my office policy to destroy clients’ records 7 years after the end of our therapy. Until then, I will keep your case records in a safe place.
If I must discontinue our relationship because of illness, death, disability, or other presently unforeseen circumstances, you agree to the transfer of your records to another therapist who will assure their confidentiality, preservation, and appropriate access.
As part of cost control efforts an insurance company will sometimes ask for more information on symptoms, diagnoses, and my treatment methods. This information will become part of your permanent medical record. I will let you know if this should occur and what the company has asked for. Please understand that I have no control over how these records are handled at the insurance company and they may be transferred to an insurance information data bank that could be available when you apply for other types of insurance. My policy is to provide only as much information as the insurance company will need to pay your benefits.
You can review your own records that I have on file for you. You will put the request in writing to review your file. I have 30 days to respond to your request, unless the files are not easily accessible (e.g. in offsite storage), in which case I may have an additional 30 days. You may request a correction to them, but I retain the right to reject the amendment if I don’t agree with it. You can have copies of them a based on allowable rates published every year by the Ohio Department of Health. I ask you to understand and agree that you may not examine records created by anyone else and then sent to me – you may obtain them from the originator of those notes.
You have the right to ask that your information will not be shared with family members or others, unless you sign a release of information. You can also tell me if you want me to send mail or phone you at a more private address or number than, say, your home or workplace. If this is of concern to you, please tell me so that we can make arrangements. E-mail is not a secure means of communication and if you decide to use e-mail with me, you understand the risks and are willing to accept them.
I am a Licensed Professional Clinical Supervisor by the State of Ohio with over 26 years of experience working with families. I am also a Register Play Therapist with the Association for Play Therapy. For the past 17 years, I have had worked in community mental health settings providing individual, family, and marriage counseling. I provide services for children, adolescents and adults. My primary practice is with children and families. I hold these qualifications:
· Licensed Professional Clinical Counselor in the State of Ohio
· National Board Certified Counselor
About Our Appointments
The very first time I meet with you, we will need to give each other much basic information. For this reason, I usually schedule 1 hour for this first meeting. Following this, we will usually meet for a 45- 53 minute session based on needs , then less often. We can schedule meetings for both your and my convenience. I will attempt to tell you at least a month in advance of my vacations or any other times we cannot meet. Please ask about my schedule in making your own plans. An appointment is a commitment to our work. We agree to meet here and to be on time. If I am ever unable to start on time, I ask your understanding. I also assure you that you will receive the full time agreed to. If you are late, we will probably be unable to meet for the full time, because it is likely that I will have another appointment after yours. A cancelled appointment delays our work. I will consider our meetings very important and ask you to do the same. Please try not to miss sessions if you can possibly help it. When you must cancel, please give me at least a 24 hour notice. Your session time is reserved for you. I am rarely able to fill a cancelled session unless I know in advance. I understand that circumstances do happen and you may not be able to cancel within 24 hours. A broken appointment is an appointment that has been cancelled in less than 24 hours. There are times that I too may have to break an appointment due to illness or family matters. If you have a broken appointment, I may have to charge you $75 for the broken appointment based on the circumstances. Frequent no show or broken appointments may result in my termination of your treatment. You will receive a letter about this concern before your treatment is terminated. I will reserve a regular appointment time for you into the foreseeable future. I also do this for my other clients. Therefore, I am rarely able to fill a cancelled session unless I have several weeks’ notice. Please be aware that insurance companies do not reimburse for missed appointments. I cannot be responsible for any personal property or valuables you bring into this office.
It is understandable with this electronic age that clients are savvy with electronic communication, texting, emails, and video communication. I will not do therapy via skype or video conference. If it is your preference, I will schedule appointments through emails, texting, fax, or telephone voice mail messages. I understand that clients will email notes about thoughts, feelings, sensations, and insights after and before their sessions. I will keep those emails as part of your records. I will verify that I received your message, but I will not do therapy via email or texting. Please remember that communication through emails or texting is not guaranteed to arrive at the intended recipient’s address or phone number. It is your preference and right to your choice of communications.
Fees, Payments, and Billing
Payment for services is an important part of any professional relationship. This is even more true in therapy; one treatment goal is to make relationships and the duties and obligations they involve clear. You are responsible for seeing that my services are paid for. Meeting this responsibility shows your commitment and maturity.
My current regular fees are as follows. You will be given advance notice if my fees should change.
Regular therapy services: $175.00 for first session, following sessions is $125.00 for 45 -53 minute session. Please pay for each session before or at its end. I have found that this arrangement helps us stay focused on our goals, and so it works best. It also allows me to keep my fees as low as possible, because it cuts down on my bookkeeping costs. I suggest you make out your
check before each session begins, so that our time will be used best. Other payment or fee arrangements must be worked out before the end of our first meeting.
If you choose to not have me send information to your insurance company, you must select this option before each session and then pay for the session in full. I will then not report any information to your insurance company about that session.
Telephone consultations: I believe that telephone consultations may be suitable or even needed at times in our therapy. If so, I will charge you my regular fee, prorated over the time needed. If I need to have long telephone conferences with other professionals as part of your treatment, you will be billed for these at the same rate as for regular therapy services. If you are concerned about this, please be sure to discuss it with me in advance so we can set a policy that is comfortable for both of us. Of course, there is no charge for calls about appointments or similar business issues.
Extended sessions: Occasionally it may be better to go on with a session, rather than stop or postpone work on a particular issue. When this extension is more than 10 minutes I will tell you, because sessions that are extended beyond 10 minutes will be charged on a prorated basis.
Reports: I will not charge you for my time spent making routine reports to your insurance company.
I realize that my fees involve a substantial amount of money, although they are well in line with similar professionals’ charges. For you to get the best value for your money, we must work hard and well. Upon your request for additional services: letters, reports, attending meetings, and other services, I will provide you a copy of the services fee and agreement. If, however, I become involved in legal proceedings as a result of my therapy with you, you agree to pay my regular fee for all time preparing for and attending to issues involving those legal proceedings. Examples would include responding to a subpoena, attending a deposition or court hearing – which would include travel time and waiting to appear. You also agree to pay for any associated legal fees that I may incur involving those legal proceedings.
I will assume that our agreed-upon fee-paying relationship will continue as long as I provide services to you. I will assume this until you tell me in person, by telephone, or by certified mail that you wish to end it. You have a responsibility to pay for any services you receive before you end the relationship.
Because I expect all payment at the time of our meetings, I usually do not send bills. However, if we have agreed that I will bill you, I ask that the bill be paid within 5 days of when you get it.
Per your request, I will send you a statement. You will receive a receipt for services at the end of each session. The receipt will provide a description of service, method of payment, and any outstanding balance.
Depending on your financial circumstances and total medical costs for any year, psychotherapy may be a deductible expense; consult your tax advisor. Cost of transportation to and from appointments and fees paid may be deductible from the client’s personal income taxes as medical expenses.
If you think you may have trouble paying your bills on time, please discuss this with me. I will also raise the matter with you so we can arrive at a solution. If your unpaid balance reaches $100.00, I will notify you by mail. If it then remains unpaid, I may stop therapy with you if we cannot agree on a payment plan. Fees that continue unpaid after this may be turned over to small-claims court or a collection service. If I choose to do that I will report only enough information to collect fees due to me.
A late payment fee of $25.00 will be charged each month that a balance remains unpaid, since I will incur costs to rebill and other accounting costs.
If there is any problem with my charges, my billing, your insurance, or any other money-related point, please bring it to my attention. I will do the same with you. Such problems can interfere greatly with our work. They must be worked out openly and quickly.
If You Have Traditional (or “Indemnity”) Health Insurance Coverage
Because I am a licensed counselor, many health insurance plans will help you pay for therapy and other services I offer. Because health insurance is written by many different companies, I cannot tell you what your plan covers. Please read your plan’s booklet under coverage for “Outpatient Psychotherapy” or under “Treatment of Mental and Nervous Conditions.” Or call your employer’s benefits office to find out what you need to know.
If your health insurance will pay part of my fee, I will help you with your insurance claim forms. However, please keep two things in mind:
1. I had no role in deciding what your insurance covers. Your employer or you (if you have individual coverage) decided which, if any, services will be covered and how much you have to pay. You are responsible for checking your insurance coverage, deductibles, payment rates, copayments, and so forth. Your insurance contract is between you and your insurance company; it is not between me and the insurance company.
2. You—not your insurance company or any other person or company—are responsible for paying the fees we agree upon. If you ask me to bill a separated spouse, a relative, or an insurance company, and I do not receive payment on time, I will then expect this payment from you.
If You Have a Managed Care Contract
If you belong to a health maintenance organization (HMO) or preferred provider organization (PPO), or have another kind of health insurance with managed care, decisions about what kind of care you need and how much of it you can receive will be reviewed by the plan. The plan has rules, limits, and procedures that we should discuss. Please bring your health insurance plan’s description of services to one of our early meetings, so that we can talk about it and decide what to do.
I will provide information about you to your insurance company only with your informed and written consent. I may send this information by mail or by fax. My office will try its best to
maintain the privacy of your records. I am not a member of any health insurance plans or panels. Health insurance is a contract between you (or your employer) and your insurer; I am not part of that contract. However, I will supply you with an invoice for my services with the standard diagnostic and procedure codes for billing purposes, the times we met, my charges, and your payments. You can use this to apply for reimbursement.
If You Need to Contact Me
I cannot promise that I will be available at all times. Although I am in the office Tuesday through Saturday, I usually do not take phone calls when I am with a client. You can always leave a message with my confidential voicemail, and I will return your call as soon as I can. Generally, I will return messages daily except on Sundays and holidays. If you have a behavioral or emotional crisis and cannot reach me by telephone, you or your family members should call one of the following community emergency agencies:
Netcare 276-2273 or your local emergency room.
If I Need to Contact Someone about You
If there is an emergency during our work together, or I become concerned about your personal safety, I may be required by law and by the rules of my profession to contact someone close to you—perhaps a relative, spouse, or close friend. I may also be required to contact this person, or the authorities, if I become concerned about your harming someone else. Please write down the name and information of your chosen contact person on the client questionnaire.
As a professional counselor, I naturally want to know more about how therapy helps people. To understand therapy better, I must collect information about clients before, during, and after therapy. Therefore, I am asking you to help me by filling out some questionnaires about different parts of your life-relationships, changes, concerns, attitudes, and other areas.
If, as part of our therapy, you create and provide to me records, notes, artworks, or any other documents or materials, I will return the originals to you at your written request but will retain copies.
Although I share an office space with Jennifer Dorn, LPCC, (dba Dorn Counseling and Consulting), the practices are not otherwise affiliated in any way and each practice is an independent practice.
Statement of Principles and Complaint Procedures
It is my intention to fully abide by all the rules of the American Counselor Association and Ohio CSWMFT Board.
Problems can arise in our relationship, just as in any other relationship. If you are not satisfied with any area of our work, please raise your concerns with me at once. Our work together will be slower and harder if your concerns with me are not worked out. I will make every effort to hear any complaints you have and to seek solutions to them. If you feel that I (or any other counselor) have treated you unfairly or have even broken a professional rule, please tell me and hopefully we can resolve your issues. I will never retaliate against you for questioning me.
In my practice as a counselor I do not discriminate against clients because of any of these factors: age, sex, marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran status, physical or mental disability, health status, sexual orientation, or criminal record unrelated to present dangerousness. This is a personal commitment, as well as being required by federal, state, and local laws and regulations. I will always take steps to advance and support the values of equal opportunity, human dignity, and racial/ethnic/cultural diversity. If you believe you have been discriminated against, please bring this matter to my attention immediately.
THIS NOTICE DESCRIBES HOW MENTAL HEALTH AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes in most instances without your consent under HIPAA, but I will obtain consent in another form for disclosing outside of my practice, except as otherwise outlined in this Policy. In all instances I will only disclose the minimum necessary information in order to accomplish the intended purpose. To help clarify these terms, here are some definitions:
· “PHI” refers to information in your health record that could identify you.
· “Treatment, Payment and Health Care Operations”
– Treatmentis when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another therapist.
- Paymentis when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage, which would include an audit.
- Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
· “Use” applies only to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· “Disclosure” applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written
permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you
before releasing this information, including uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI. Examples of disclosures requiring an authorization include disclosures to your partner, your spouse, your children, except in some limited instances where they are involved in your health care, in which case I will obtain your consent first.
I may use or disclose PHI without your consent or authorization as allowed by law, including, under the following circumstances:
· Serious Threat to Health or Safety:If I believe that you pose a clear and substantial risk of imminent serious harm, or a clear and present danger, to yourself or another person I may disclose your relevant confidential information to public authorities, the potential victim, other professionals, and/or your family in order to protect against such harm. If you communicate to me an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly identifiable victims, and I believe you have the intent and ability to carry out the threat, then I may take one or more of the following actions in a timely manner: 1) take steps to hospitalize you on an emergency basis, 2) establish and undertake a treatment plan calculated to eliminate the possibility that you will carry out the threat, and initiate arrangements for a second opinion risk assessment with another mental health professional, 3) communicate to a law enforcement agency and, if feasible, to the potential victim(s), or victim's parent or guardian if a minor, all of the following information: a) the nature of the threat, b) your identity, and c) the identity of the potential victim(s). I will inform you about these notices and obtain your written consent, if I deem it appropriate under the circumstances.
· Worker’s Compensation: If you file a worker’s compensation claim, I may be required to give your mental health information to relevant parties and officials.
· Felony Reporting: I may be required or allowed to report any felony that you report to me that has been or is being committed.
· For Health Oversight Activities: I may use and disclose PHI if a government agency is requesting the information for health oversight activities. Some examples could be audits, investigations, or licensure and disciplinary activities conducted by agencies required by law to take specified actions to monitor health care providers, or reporting information to control disease, injury or disability.
· For Specific Governmental Functions: I may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, and for national security reasons, such as for protection of the President.
· For Lawsuits and Other Legal Proceedings: If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by law. I cannot provide any information without your (or your personal or legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
· Abuse, Neglect, and Domestic Violence: If I know or have reason to suspect that a child under 18 years of age or a mentally retarded, developmentally disabled, or physically impaired child under 21 years of age has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect of the child or developmentally disabled individual under 21, the law requires that I file a report with the appropriate government agency, usually the County Children Services Agency. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to believe that a developmentally disabled adult, or an elderly adult in an independent living setting or in a nursing home is being abused, neglected, or exploited, the law requires that I report such belief to the appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. If I know or have reasonable cause to believe that a patient or client has been the victim of domestic violence, I must note that knowledge or belief and the basis for it in the patient’s or client records.
· To Coroners and Medical Examiners: I may disclose PHI to coroners and medical examiners to assist in the identification of a deceased person and to determine a cause of death.
· For 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, summons or similar process, subject to all applicable legal requirements.
· Required by Law. I will disclose health information about you when required to do so by federal, state or local law.
· Public Health Risks. I may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, non-accidental physical injuries, reactions to medications or problems with products.
· Information Not Personally Identifiable. I may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Other uses and disclosures will require your signed authorization.
IV. Patient’s Rights and Duties
· Right to Request Restrictions and Disclosures–You have the right to request restrictions on certain uses and disclosures of protected health information about you for treatment, payment or health care operations. However, I am not required to agree to a restriction you request, except under certain limited circumstances, and will notify you if that is the case. One right that I may not deny is your right to request that no information be sent to your health care plan if you pay in full for the health care plan
service ahead of time. If you select this option then you must request it and pay in full each time a service is going to be provided. I will then not send any information to the health care plan for that session unless I am required by law to release this information.
· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. If your request is reasonable, then I will honor it.
· Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record, except under some limited circumstances. This does not apply to information created for use in a civil, criminal or administrative action or proceeding. I may charge you reasonable amounts for copies, mailing or associated supplies. I may deny your request to inspect and/or copy your record or parts of your record in certain limited circumstances. If you are denied copies of or access to your PHI, you may ask that my denial be reviewed.
· Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request, but will note that you made the request. Upon your request, I will discuss with you the details of the amendment process.
· Right to an Accounting – With certain exceptions, you generally have the right to receive an accounting of disclosures of PHI, not including disclosures for treatment, payment or health care operations, for paper records on file for the past six years and for an accounting of disclosures made involving electronic records, including disclosures for treatment, payment or health care operations, for a period of three years. On your request I will discuss with you the details of the accounting process.
· Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
· I am required by law to maintain the privacy of PHI, to provide you with this notice of my legal duties and privacy practices with respect to PHI, and to abide by the terms of this notice.
· I reserve the right to change the privacy policies and practices described in this notice and to make those changes effective for all of the PHI I maintain.
· If I revise my policies and procedures, which I reserve the right to do, I will make available a copy of the revised notice to you on my website, if I maintain one, and one will always be available at my office. You can always request that a paper copy be sent to you by mail
· In the event that I learn that there has been an impermissible use or disclosure of your unsecured PHI, unless there is a low risk that your unsecured PHI has been compromised, I will notify you of this breach.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I make about access to your records, you may file a complaint with me and I will consider how best to resolve your complaint. Contact me, the Privacy Officer, if you wish to file a complaint with me. In the event that you aren’t satisfied with my response to your complaint, or don’t want to first file a complaint with me, then you may send a written complaint to the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. or to:
Region V, Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601. Ph. (312) 886-2359, Fax (312) 886-1807, TDD (312) 353-5693.
There will be no retaliation against you for filing a complaint.
This notice is effective as of September 23, 2013.
VII. Privacy and Security Officer
I act as my own Privacy and Security Officer. My contact information is listed at the beginning of this form.