Notice of Privacy Practices

(brief version at top, full version farther below)

Brief Version:

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I am required to notify you in writing and obtain your written consent regarding privacy procedures because of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This brief, version of the policy summarizes the detailed full-length version of the notice that is attached farther beneath. (Some of the specific words and sentences used in these documents are required by law.)

Agreeing to these statements is required by law so that consumers are made sufficiently aware of regulations, rights and policies regarding privacy. Agreeing on the separate consent form will also give me permission to bill your insurance provider if you are using insurance to pay for services.

Except in very rare circumstances, I will always obtain an additional signed consent form if any other outside contact is necessary. An example of such contact would be those situations in which we both decide it would be helpful for me to have contact with a psychiatrist or other doctor, guidance counselor or other school staff, hospital worker or probation officer. In those situations we will discuss the contact in as much detail as necessary and if we are both agreed on my making the contact, I will ask you to sign another consent form explicitly designated to that party. The rare circumstances in which I would not obtain another consent form would involve legal orders or threat of serious harm during which I could not contact you to discuss and/or obtain another signed written consent. Another rare circumstance in which I anonymously disclose information would be that in which a government or other organization is collecting anonymous data regarding mental health treatment. An example of this would be my submitting data on the age range of my clients who suffered from a certain condition.

It is your legal right to know exactly what has been communicated to your insurance company or any outside party. Please read my full-length “Notice of Privacy Practices”, ask me any questions about the privacy procedures and, if you are comfortable doing so, indicate agreement on the separate form.

If you do not wish to sign this consent form, let's discuss your concerns. The issues and language can be hard to understand and I do not want you to sign anything with which you are not comfortable. We must address any concerns because, under the HIPAA law, without a signed privacy practices consent form, I cannot legally treat you, your child or family. A summary of your rights regarding your health information 1. You can ask me to communicate with you in a particular way or at a certain place that is more private for you. For example, you can ask me to call you at home, and not at work, to schedule or cancel an appointment. 2. You can ask me to limit what I tell people involved in your care or the payment for your care, such as family members and friends. 3. You have the right to look at the health information I have about you, such as your medical and billing records. You can get a copy of these records. 4. If you believe that the information in your records is incorrect or missing something important, you can ask me to make additions to your records to correct the situation. 5. You have the right to a copy of this notice. If I change this notice, I will inform you and give you a new copy and consent form to sign. 6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me and with the Secretary of the U.S. Department of Health and Human Services. Filing a complaint will not change the health care I provide to you in any way. If you have any questions or concerns regarding this notice or my health information privacy policies, it is important that we discuss your questions or concerns The effective date of this notice is 9/29/11.