Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland law. However, in the following situations, no authorization is required: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency, usually the local office of the Department of Social Services. Once such a report is filed, I may be required to provide additional information. If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 2 contracts
Samples: karinmosk.com, karinmosk.com
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a consent written Authorization form that meets certain specific legal requirements imposed by HIPAA and/or Maryland lawstate law and HIPAA. HoweverBut there are some situations where I am permitted or required to disclose information without either your consent or authorization: • If a patient threatens to harm themself, in the following situations, no authorization is required: I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important essential to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information)Record. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, • I may be required court-ordered to provide it for themrelease treatment information and records in alleged criminal or civil liability cases. If In addition, if a patient client files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order client to defend myself. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some • If a government agency requests the information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency, usually the local office of the Department of Social Services. Once such a report is filedfor health oversight activities under their legal authority, I may be required to provide additional informationit. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(syou feel something should not be shared with your partner, please do not tell me your secret(s). At such times, I it may be required most appropriate for you to take protective actions. These actions may include establishing seek the support of an individual therapist who is independent of your couple’s treatment and undertaking a treatment plan that is calculated to eliminate who will consult with me regarding the possibility that broad issues and not the patient will carry out the threat, seeking hospitalization specifics of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessaryyour secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important essential that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 2 contracts
Samples: laurastruhl.com, laurastruhl.com
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I the Practice can only release information about regarding your treatment to others if you sign we have a consent signed Authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. HoweverThere are other situations that require that you provide written, in the following situationsadvance consent. Your signature on this Agreement provides consent for those activities, no authorization is requiredas follows: I • We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my patientour patients. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel that it is important to our work together. I We will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient seriously threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact either a medical professional or the police who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where we are permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I We cannot provide any information without your (or your 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 us to disclose information. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a patient files a complaint or lawsuit against methe Practice, I we may disclose relevant information regarding that patient in order to defend myselfourselves. • If a patient files a worker’s compensation claim, we must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought. • There are some situations in which I am the Practice is legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my our practice: . • If I we have reason cause to believe that a childchild under 18 has been or may be abused or neglected (including physical injury, adolescentsubstantial threat of harm, mental or emotional injury, or vulnerable adult has been subjected to abuse any kind of sexual contact or neglectconduct), or that a vulnerable adult has been subjected to self-child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect, or exploitation, the law requires that I file we make a report with to the appropriate government governmental agency, usually the local office of the Department of Social Protective and Regulatory Services. Once such a report is filed, I we may be required to provide additional information. • If I know we determine that there is a patient has a propensity for violence and probability that the patient indicates that he/she has the intention to will inflict imminent physical injury on another, or that the patient will inflict imminent physical, mental or emotional harm upon a specified victim(s)himself/herself, I or others, we may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated action by disclosing information to eliminate the possibility that the patient will carry out the threat, seeking medical or law enforcement personnel or by securing hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we you and your clinician discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 1 contract
Samples: psychologyhoustonpc.com
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a consent written Authorization form that meets certain legal requirements imposed by HIPAA state law and/or Maryland lawHIPAA. HoweverBut, in the following situationsthere are some situations where I am permitted or required to disclose information without either your consent or authorization: • If a patient threatens to harm himself/herself, no authorization is required: I may be obligated to seek hospitalization for him/ her, or to contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient, or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice Record. • In cases of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers alleged criminal or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activitiescivil liability, I may be required court ordered to provide it for themrelease treatment information and/or records. If In addition, if a patient client files a complaint or lawsuit against me, I may disclose relevant information regarding that patient client in order to defend myself. There are some situations in which I am legally obligated • If a government agency is requesting the information for health oversight activities pursuant to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency, usually the local office of the Department of Social Services. Once such a report is filedtheir legal authority, I may be required to provide additional informationit for them. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an elderly person or dependent adult to protect the elderly person or dependent adult involved. ▪ I am obliged under the law to report to the appropriate authorities any instance where a patient discloses they have accessed, streamed, or downloaded material where a child is engaged in an obscene sexual act. ▪ In couples or family treatment, please be aware that information shared with me will be disclosed to your partner or family if they are participating in treatment. I will not agree to hold secrets on any one partner’s behalf. If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(syou feel something should not be shared with your partner, please do not tell me your secret(s). At such times, I it may be required most appropriate for you to take protective actions. These actions may include establishing seek the support of an individual therapist who is independent of your couple’s treatment, and undertaking a treatment plan that is calculated to eliminate who will consult with me regarding the possibility that broad issues, and not the patient will carry out the threat, seeking hospitalization specifics of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessaryyour secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 1 contract
Samples: laurastruhl.com
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I the office can only release information about your treatment to others only if you sign a consent written authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. However, Further information about these limitations can be found in the following situationsNotice posted in the waiting room. Absolute confidentiality and privacy of your medical records cannot be guaranteed, no authorization is requiredespecially when it involves third party payers, such as an insurance carrier. At the outset of treatment, and thereafter, the office submits paperwork to your insurance carrier which may include specific information about your mental health, such as diagnosis, and medical conditions. Insurance carriers frequently conduct a clinical audit which includes chart review. There are some situations when Xx. Xxxxx and Xx. Xxxxxxxxx are permitted or required to disclose information without either your consent or authorization, For example: I may occasionally find it helpful ! If you present a serious risk to consult other your own health and mental health professionals about a casesafety or to that of another person, we must warn the potential victim(s), contact the police, or get you hospitalized. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. ! If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a patient files file a complaint or lawsuit against meXx. Xxxxx or Xx. Xxxxxxxxx, I may then as part of their defense they are permitted to disclose relevant information regarding you. ! If you file a worker’s compensation claim, information directly related to that patient in order claim must be provided to defend myselfthe Workers’ Compensation Commission, upon written request. There ! As clinicians, we are some situations in which I am legally obligated to take actions, which I believe actions that are necessary to attempt to protect others from harm and I harm. We may have be required to reveal some information about a patient’s your treatment. These situations are unusual in my practice: If I have For example, if there is reason to believe know or suspect that a child, adolescentchild has been abused or neglected by an adult, or vulnerable adult has been subjected to a victim of sexual abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitationby another child, the law requires that I file a report with we contact the appropriate government agency, usually the local office of police and/or the Department of Social ServicesChildren, Youth, and Families. Once such a report is filed, I we may be required to provide additional information. If I know that a patient has a propensity for violence RETURN OF BORROWED ITEMS: Personal books and the patient indicates that he/she has the intention electronic media are made available to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actionsencourage learning. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threatKindly return them when instructed. If I believe that there is an imminent risk that a patient will inflict serious physical harm they are lost or death misplaced, you should replace them (in-kind or monetarily). Revised Therapy Agreement, January, 2020 [AMF/MSS] Acknowledgement of Therapy Agreement Your signature on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns “acknowledgement” page affirms that you may havehave read, now or in the future. The laws governing confidentiality can be quite complexunderstood, and I am not agree to all our office policies. This document represents an attorneyagreement between us, revocable in writing by you at any time. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and proceduresYour signature, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy date you signed below, indicates that you have read the information in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request the Therapy Agreement and that they you agree to my sharing occasional general information about abide by the progress terms it sets forth. Patient signature: Date: Please return this signed and dated “Acknowledgement of treatment with his/her parentsTherapy Agreement” page to Xx. Unless I feel discussing disclosure prior Xxxxx or Xx. Xxxxxxxxx at your first appointment. Or you can send it back to parental notification is not realisticus: 000 Xxxxxx Xxxx, such as when the child is in danger or is a danger to someone elseSuite 12, I will discuss with the childGreenville, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.R.I. 02828
Appears in 1 contract
Samples: Therapy Agreement
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland law. However, in the following situations, no authorization is required: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency, usually the local office of the Department of Social Services. Once such a report is filed, I may be required to provide additional information. If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to regarding clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 1 contract
Samples: karinmosk.com
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a consent written Authorization to Release Information form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. HoweverThere are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. • If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm themselves, I may be obligated to seek hospitalization for them or to contact family members or others who can help provide protection. If a similar situation occurs in the following situationscourse of our work together, no authorization is required: I will attempt to fully discuss it with you before taking any action. • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals professions are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my HIPAA Notice of Psychologist’s Policies and Privacy Practices to Protect the Privacy of Your Health Information). Disclosures • You should be aware that I may employ administrative staff. In those cases, I will need to share protected information with those individuals for administrative purposes, such as billing and quality assurance. All staff members will be trained about protecting your privacy and will agree not to release any information outside of the practice without my permission. There are some situations where I am permitted or required by health insurers to disclose information without either your consent or to collect overdue fees Authorization. They are discussed elsewhere in this Agreement. as follows: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (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 where a court would be likely to order me to disclose information. • If a government agency the Alabama Board of Examiners in Psychology is requesting the information for health oversight activitiesan investigation of my practice, I may be am required to provide it for them. • If a patient files a complaint compliant or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, I may disclose information relevant to that claim to the patient’s employer or the insurer. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm harm, and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: • If I have reason to believe know or suspect that a child, adolescent, or vulnerable adult child under the age of 19 has been subjected to abuse abused or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitationneglected, the law requires that I file a report with the appropriate government agency, usually the local office of the Alabama Department of Social ServicesHuman Resources. Once such a report is filed, I may be required to provide additional information. • If I know or suspect that an elderly or disabled adult has been abused, neglected, exploited, sexually, emotionally, or physically abused, the law requires that I file a patient has a propensity for violence and report with the patient indicates that he/she has appropriate governmental agency, usually the intention to inflict imminent physical injury upon a specified victim(s)Alabama Department of Human Resources. Once such report is filed, I may be required to take protective actionsprovide additional information. These actions • If I believe that disclosing information about you is necessary to prevent or lessen a serious and imminent threat to the health and safety of an identifiable person(s), I may include establishing and undertaking a treatment plan disclose that is calculated information, but only to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim those reasonably able to prevent or the police about lessen the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arisesone of these situations arise, I will make every effort to fully discuss it with you before taking any action action, and I will try to limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws PATIENT’S RIGHTS HIPAA provided you with several new or expanded rights with regard to your Clinical Record and standards disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the profession require that location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the HIPAA Notice of Psychologist’s Policies and Privacy Practices of Your Health Information, and my procedures. I will be happy to discuss any of these rights with you. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information you in two sets of professional records. One set is constitutes your clinical recordClinical Record. It includes information about your reasons for seeking therapy and how these and related issues impact on therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards the those goals, your medical treatment and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, test results, and any reports that have been sent to anyone, including reports to your insurance carriers or otherscarrier. You may chooseIf you provide me with an appropriate written request, in writing, you have the right to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important for a fee, except in unusual circumstances that involve danger to first review them together you or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be releasedothers. In those situations, the person would you have a right to a summary and to have their your record sent to another mental health provider. A copying fee The exceptions to this policy are contained in the attached Notice of $.60 per page Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information form. If I refuse your request for access to your records, you have a right of review, which we will be chargeddiscuss with you upon request. There In addition, I may be other associated costs for review of records. The other set I also keep in some instances is a set of psychotherapy notesPsychotherapy Notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client patient to clientpatient, they can include the contents of our conservationsconversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical recordClinical Record. These psychotherapy notes Psychotherapy Notes are kept separate from your clinical recordClinical Record. While insurance companies can request and receive a copy of your clinical recordClinical Record, they cannot receive a copy of your psychotherapy notes Psychotherapy Notes without your signed, written authorizationAuthorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal. You If I die or become incapacitated, there is a probability that a designated Professional Executor may examine take control of patient’s records and contact them. PROFESSIONAL FEES My fee for the initial consultation is $187.00. Sessions lengths can vary. Sessions between 16 and 37 minutes are billed at $93.00. Sessions between 38 and 52 minutes are billed at $140.00. Sessions over 52 minutes are billed at $187.00. Additional fees may be applied for additional services and interactive complexity, such as brief consultation with family members. Most insurances and managed care organizations require a co-pay and/or receive a copy deductible for which you are responsible. If you are using your insurance, you are responsible for verification of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious coverage and for obtaining pre- authorization for these services prior to your healthfirst visit. Patient Rights HIPAA provides OTHER FEES If we meet more than the usual time, I will charge accordingly. In addition to weekly appointments, I charge this same hourly rate for other professional services you may need, though I will prorate the hourly cost if I work for periods of less than one hour. Other professional services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with expanded rights with regard to clinical records and disclosures other professionals you have authorized, preparation of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedurestreatment summaries, and the attached HIPAA notice formtime spent performing any other service you may request of me. Minors & Parents Parents If a check is returned, the returned check fee is $30.00. Any court appearance, or deposition, or the provision of clients 16 years documents for any attorney or for the court will be billed at a rate of age who $200 per hour, and will include preparation and travel time. You will be responsible for all such fees related to your evaluation or treatment, payable at the time any such court-related services are not emancipated may requested. The fee for Medical/Mental Health Records or written communications to you or on your behalf will be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress a minimum of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents $20 and preferably both the child and I will talk with the parents togethercan increase depending on time spent.
Appears in 1 contract
Samples: Patient Agreement
Limits of Confidentiality. The law protects the privacy of all communications communication between a patient and a psychologisttherapist. In most situations, I we can only release information about your treatment to others if you sign a consent written authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPPA. HoweverThere are other situations that require only that you provide written, in the following situationsadvance consent. Your signature on this Agreement provides consent for those activities, no authorization is requiredas follows: I ❖ We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my our patient. The other professionals are also legally bound to keep the information confidential. If you don’t do not object, I we will not tell you about these consultations unless I we feel that it is important to our work together. I We will note all consultations in your Clinical Record (clinical record. ❖ We employ administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. ❖ We may have contracts with an electronic billing service. As required by HIPAA, we have a formal business associate contract with this business in which is called “PHI” it promises to maintain the confidentiality of this data except as specifically allowed in my Notice the contract or otherwise required by law. If you wish, we can provide you with the name of Psychologist’s Policies and Practices to Protect the Privacy this organization and/or a blank copy of Your Health Information)this contract. ❖ Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. There are some situations where we are permitted or required to disclose information without either your consent or authorization: ❖ If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services that we provided you, such information is protected by the psychologist/counselor-patient privilege law. I We cannot provide any information without your 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 us to disclose information. ❖ If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. ❖ If a patient files a complaint or lawsuit against me, I we may disclose relevant information regarding that patient in order to defend myself. ❖ If we are providing treatment for conditions directly related to a worker’s compensation claim, we may have to submit such records, upon appropriate request, to the Chairman of the Worker’s Compensation Board on such forms and at such times as the chairman may require. There are some situations in which I am we are legally obligated to take actions, actions which I we believe are necessary to attempt to protect others from harm harm, and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: ❖ If I have reason we receive information in our professional capacity from a child or the parents or guardian or other custodian of a child that gives me reasonable cause to believe suspect that a child is an abused or neglected child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a we report with to the appropriate government governmental agency, usually the local office of the Department of Social Services. If we believe that a child has been or may be abused or neglected by any other person, we must report this to the appropriate law enforcement agency. Once such a report is filed, I we may be required to provide additional information. ❖ If I know we have reason to believe that a vulnerable adult has been or is likely to be abused, neglected, or exploited, the law requires that we file a report to the Adult Protective Services Program. Once such a report is filed, we may be required to provide additional information. ❖ If a patient has a propensity for violence and the patient indicates that he/she has the intention communicates an immediate threat of serious physical harm to inflict imminent physical injury upon a specified victim(s)an identifiable victim, I we may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate notifying the possibility that potential victim, contacting the patient will carry out the threatpolice, or seeking hospitalization of for the patient and/or informing the potential victim or the police about the threatpatient. ❖ If I believe that there is an imminent risk that a patient will inflict serious physical threatens to harm or death on himhimself/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I we may be required obligated to take appropriate protective actionsseek hospitalization for him/her, including initiating hospitalizations and/or notifying or to contact family members or others who can protect help provide protection. ❖ If a patient reveals his or her intent to commit a crime, we may be required to take preventative action, such as calling the patientpolice. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action action, and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am we are not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to clinical records your Clinical Records and disclosures of protected health information. These rights include requesting that I we amend your record; requesting restrictions on what information from your clinical record Clinical Records is discloseddisclosed to others; requesting an accounting of disclosuresmost disclosures of protected health information that you have neither consented to nor authorized; determining where the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this agreementAgreement, my the notice form, and our privacy policies and procedures, . Your signature below indicates that you have read the information in this document and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general abide by its terms during our professional relationship. Your signature below also serves as an acknowledgement that you have been offered a copy of our summary of patient privacy notice forms. PLEASE PRINT: Client’s Name: Your name (parent/guardian) PLEASE SIGN: Date: Client (or parent/guardian if client is a minor) Date: JSS Behavioral Services Clinician Date: Xxxxxxx X. Xxxxxx, Psy.D., BCBA-D Licensed Psychologist #1239 Consent for Treatment I have read the information contained in this document and agree to abide by its terms during our professional relationship. I understand that I am responsible for payment of any fees which insurance does not pay or cover. SIGNATURE AND DATE PRINTED NAME Insurance Authorization I authorize the release of any medical or other information necessary to process insurance claims for services rendered. I also request payment of medical benefits to the undersigned physician or party who accepts assignment. SIGNATURE AND DATE PRINTED NAME SOUTH CAROLINA PRIVACY NOTICE FORM Practices to Protect the Privacy of Your Health Information I have read and received the information contained in this document and understand how the Health Insurance and Portability and Accountability Act (HIPAA) impacts clinical and medical information about the progress of treatment with his/her parentsme and how I can get access to this information. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, am also aware that should I will discuss with the child, what have any questions concerning this policy I think is in their best interest am free to discuss with them at our next session or at any time in the parents future. SIGNATURE AND DATE PRINTED 0000 Xxxxxxxxxx Xxxx Xxxxx X0X North Charleston, SC 29406 JSS Behavioral Services A Center for Family-Focused Behavioral Care Phone: 000.000.0000 Fax: 000.000.0000 Website: xxx.XXXXxxxxxxxxx.xxx OBTAINING/RELEASING INFORMATION FORM I, , hereby authorize the staff of JSS Behavioral Services to obtain/release information pertaining to ‘s evaluation and/or treatment to/from the following: for the purpose(s) of: Requested information/documents: I have been informed that I may revoke this authorization by written or oral communication to JSS Behavioral Services. I certify that this form has been fully explained to me and preferably both the child and that I will talk with the parents togetherunderstand its contents.
Appears in 1 contract
Samples: drjeffselman.com
Limits of Confidentiality. The law protects the privacy of all communications between a patient client and a psychologist. In most situations, I can only release information about you and/or your child’s treatment to others if you sign a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland lawwritten authorization form. However, in the following certain situations, no authorization is required: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt actions in order to protect you and/or your child or others from harm and I may have to reveal some information about a patient’s treatmentharm. These situations are unusual in my practice: • If I have reason reasonable cause to believe that a child, adolescent, or vulnerable adult child under the age of 18 has been subjected to suffered abuse or neglect, or that a vulnerable adult has been subjected I am legally mandated to self-neglect, or exploitation, the law requires that I file make a report with to the appropriate government agency, usually proper law enforcement agency or to the local office state department of the Department of Social Servicessocial and health services. Once such a report is filed, I may be required to provide additional information. • If I know have reason to believe that a patient has vulnerable adult is being abandoned, abused, financially exploited or neglected, I am legally mandated to make a propensity for violence report to the proper law enforcement agency or to the state department of social and the patient indicates that he/she has the intention to inflict imminent physical injury upon health services. Once such a specified victim(s)report is filed, I may be required to provide additional information. • If I believe that you present a clear, imminent risk of serious harm to yourself, I may be required to disclose information in order to take protective actions These actions may include contacting family members or others who can assist in protecting you, or seeking your hospitalization. • If you have made a specific threat of violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required to disclose information in order to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing notifying the potential victim or victim, contacting the police about or seeking your hospitalization. Further, the threatlaw allows the release of confidential information without your authorization in the following situations: a) to a person who I believe is providing healthcare to my identified client, b) to any healthcare provider who I believe has previously provided my identified client healthcare to the extent necessary for me to provide healthcare to you and/or your child, unless you instruct me in writing not to make such disclosure, and finally c) to an immediate family member or any other individual with whom you have a close personal relationship if the disclosure is appropriate within good professional practice, unless you instruct me in writing not to make the disclosure. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for you are under the patient’s emergency health care needsage of 18, I may be required have to take appropriate protective actions, including initiating hospitalizations and/or notifying family members share information with your legal guardian about what we discuss in therapy or others who can protect the patientduring an evaluation. I will act in your best interest when disclosing information to your legal guardian. If such a situation arisesany of these situations arise, I will make every effort to fully discuss it with you before taking any action action, and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing If you about potential problems, it is important that we discuss have any questions that I haven’t addressed either in this document or concerns with you personally, please feel free to ask me for clarification at any time. I look forward to working with you. Agreement for Psychological Services Client’s Name: Date of Birth: The Health Insurance Portability and Accountability Act (HIPAA), requires that you may have, now or in the future. The laws governing confidentiality can be quite complex, sign this “Agreement for Psychological Services” and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive have provided you with a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, “Notice of Information Practices.” This Policy further explains HIPAA and the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy protection of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected personal health information. These include requesting Your signature represents an agreement between us. You can revoke this Agreement in writing at any time. I hereby acknowledge that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting have received and have been given an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right opportunity to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.read copies of:
Appears in 1 contract
Samples: Service Agreement
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistbehavioral health treatment provider. In most situations, I PBHP can only release information about your treatment to others if you sign a consent written authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland Illinois law. However, in the following situations, no authorization is required: I • A PBHP treatment provider may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I your treatment provider will make every effort to avoid revealing the identity of my patientyour identity. The other professionals are also legally bound to keep the information confidential. If you don’t do not object, I your provider will not tell you about these consultations unless I feel that he/she feels it is important to our your work together. I Your provider will note all consultations in your Clinical Record (which is called referred to as “PHI” in my the Notice of Psychologist’s Palos Behavioral Health Professionals’ Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that your PBHP treatment provider practices with other mental health professionals and that PBHP employs administrative staff. In most cases, your treatment provider will need to share protected information with these individuals for both clinician and administrative purposes, such as scheduling, billing, and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege lawMental Health and Developmental Disabilities Confidentiality Act. I PBHP cannot provide disclose any information without your written authorization, or a court order. If you are involved in or are contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me your treatment provider to disclose information. • If a government agency is requesting the information for health oversight activities, I PBHP may be required to provide it for them. • If a patient files a complaint or lawsuit against mea treatment provider, I that treatment provider may disclose relevant information regarding that patient in order to defend myselfprovide defense. • If you file a worker’s compensation claim, and your treatment provider is rendering treatment or services in accordance with the provisions of the Illinois Workers’ Compensation law, the treatment provider must, upon appropriate request, provide a copy of your record to your employer or his/her appropriate designee. There are some situations in which I am a PBHP treatment provider is legally obligated to take actions, which I believe are action that the treatment provider believes is necessary to attempt to protect others from harm and I harm. To this end, the treatment provider may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: • If I have reason a PBHP treatment provider has reasonable cause to believe that a child under 18 years may be, in the providers’ professional capacity, an abused or neglected child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I the provider file a report with the appropriate government agency, usually the local office of the Department of Social Children and Family Services. Once such a report is filed, I the provider may be required to provide additional information. • If I know a PBHP treatment provider has reason to believe that an adult over 60 years is living in a patient domestic situation and has been abused or neglected in the preceding 12 months, the law requires that the provider file a propensity for violence and report with the patient indicates that he/she has agency designated to receive such reports by the intention to inflict imminent physical injury upon Department of Aging. Once such a specified victim(s)report is filed, I the provider may be required to provide additional information. • If you have made a specific threat of violence against another or if your PBHP treatment provider believes that you present and clear, imminent risk of serious physical harm to another, the provider may be required to disclose information in order to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing notifying the potential victim victim, contacting the police, or the police about the threatseeking your hospitalization. • If I believe your PBHP treatment provider believes that there is an you present a clear, imminent risk that a patient will inflict of serious physical harm or mental injury or death on him/herselfto yourself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I provider may be required to disclose information in order to take appropriate protective actions, including initiating hospitalizations and/or notifying . These actions may include seeking your hospitalization or contacting family members or others who can protect assist in protecting you. • Currently, a new law in Illinois requires all healthcare providers to report persons deemed unstable to the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessaryFirearms Owner Identification program (FOID) so that possible use of firearms in situations like school shootings can be prevented. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we you and your treatment provider discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am PBHP treatment providers are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 1 contract
Samples: Outpatient Services Agreement
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form. But there are some situations where I am permitted or required to disclose information without either your consent form that meets certain legal requirements imposed by HIPAA and/or Maryland law. However, in the following situations, no authorization is requiredor authorization: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t do not object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information)Record. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentabout the professional services that I have provided you and/or the records thereof, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legally- appointed representative’s) written authorization, or a court order, or compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required) has stated valid legal grounds for obtaining PHI, and I do not have grounds for objecting under state law (or you have instructed me not to object). 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 government agency is requesting the information for health oversight activitiesactivities pursuant to their legal authority, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition, to the worker’s compensation insurer. There are some situations in which I am legally obligated required to break confidentiality and take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatmentharm. These situations are unusual in my practice: • If I have reason to believe knowledge of a child under 18, or reasonably suspect that a childchild under 18 that I have observed, adolescent, or vulnerable adult has been subjected to the victim of child abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government governmental agency, usually the local office county welfare department. I also may make a report if I know or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional well being is endangered in any other way (other than physical or sexual abuse, or neglect). • If I observe or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if an elder or dependent adult credibly reports that he or she has experienced behavior including an act or omission constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, the law requires that I report to the appropriate government agency. • If a patient, or a family member, communicates a serious threat by the patient of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the Department of Social Servicespatient, or contact others, who can assist in protecting the victim. Once • If I have reasonable cause to believe that the patient is in such a report is filedmental or emotional condition as to be dangerous to him or herself, I may be required to provide additional information. If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be required obligated to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threataction, including seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying contacting family members or others others, including the police, who can protect the patienthelp provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that Pursuant to HIPAA, I may keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information you in two sets of professional records. One set is constitutes your clinical recordClinical Record. It includes information about your reasons for seeking therapy and how these and related issues impact on your lifetherapy, your presenting problems, diagnosis, goals for treatment, progress towards the treatment goals, your progress, medical treatment and social history, treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, billing records, and any reports that have been sent to anyone, including reports to your insurance carriers carrier. Except in unusual circumstances in that disclosure would physically endanger you and/or others or others. You makes reference to another person (unless such other person is a health care provider), you may choose, in writing, to examine and/or receive a copy of your clinical recordClinical Record, if you request it in writing. Because these are professional records records, they can be misinterpreted it would be important and/or upsetting to first untrained readers. For this reason, I recommend that you initially review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s lifepresence, then clinical records would not be released. In those situations, the person would or have a right to a summary and to have their record sent them forwarded to another mental health providerprofessional so you can discuss the contents. A There will be a copying fee of $.60 25 cents per page page. If I refuse your request for access to your Clinical Records, you have a right of review (except for information supplied to me confidentially by others) which I will be chargeddiscuss with you upon request. There In addition, I may be other associated costs for review of records. The other set I also keep in some instances is a set of psychotherapy notesPsychotherapy Notes. These notes Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservationsconversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical recordClinical Record. They may include information from others provided to me confidentially. These psychotherapy notes Psychotherapy Notes are kept separate from your clinical recordClinical Record. While Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signedwritten, written authorizationsigned Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious refusal to your healthprovide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to clinical records your Clinical Records and disclosures of protected health informationPHI. These rights include requesting that I amend your record; requesting restrictions on what information from your clinical record Clinical Records is discloseddisclosed to others; requesting an accounting of disclosuresmost disclosures of PHI that you have neither consented to nor authorized; determining where protected information the location to which PHI disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this agreementAgreement, my policies and proceduresthe attached Notice Form, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents Privacy Policies and preferably both the child and I will talk with the parents togetherProcedures.
Appears in 1 contract
Samples: www.shireenrafatphd.com
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland law. However, in the following situations, no authorization is required: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency, usually the local office of the Department of Social Services. Once such a report is filed, I may be required to provide additional information. If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- 16 to 18-year-year olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 1 contract
Samples: karinmosk.com
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I the Practice can only release information about your treatment to others if you sign a consent written Authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. HoweverThere are other situations that require only that you provide written, in the following situationsadvance consent. Your signature on this Agreement provides consent for those activities, no authorization is requiredas follows: I We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my patientour patients. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel that it is important to our work together. I We will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a patient seriously threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where we are permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I We cannot provide any information without your (or your 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 us to disclose information. If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. If a patient files a complaint or lawsuit against methe Practice, I we may disclose relevant information regarding that patient in order to defend myselfourselves. If a patient files a worker’s compensation claim, we must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought. There are some situations in which I am the Practice is legally obligated to take actions, which I we believe are is necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my our practice: . If I we have reason cause to believe that a childchild under 18 has been or may be abused or neglected (including physical injury, adolescentsubstantial threat of harm, mental or emotional injury, or vulnerable adult has been subjected to abuse any kind of sexual contact or neglectconduct), or that a vulnerable adult has been subjected to self-neglectchild is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I file we make a report with to the appropriate government governmental agency, usually the local office of the Department of Social Protective and Regulatory Services. Once such a report is filed, I we may be required to provide additional information. If I know we determine that there is a patient has a propensity for violence and probability that the patient indicates that he/she has the intention to will inflict imminent physical injury on another, or that the patient will inflict imminent physical, mental or emotional harm upon a specified victim(s)him/herself, I or others, we may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated action by disclosing information to eliminate the possibility that the patient will carry out the threat, seeking medical or law enforcement personnel or by securing hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we you and your clinician discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am we are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 1 contract
Samples: psychologyhoustonpc.com
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a consent written authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. HoweverThere are other situations that require only that you provide written, in the following situationsadvance consent. Your signature on this Agreement provides consent for those activities, no authorization is requiredas follows: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t n't object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “"PHI” " in my Notice of Psychologist’s 's Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers • If a patient seriously threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to collect overdue fees contact family members or others who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are discussed elsewhere in this Agreement. some situations where I am permitted or required to disclose information without either your consent or authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker's compensation claim, I must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought. • If a patient fails to pay for services I have rendered, I may disclose relevant information in a suit seeking payment. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s 's treatment. These situations are unusual in my practice: . • If I have reason cause to believe that a childchild under 18 has been or may be abused or neglected (including physical injury, adolescentsubstantial threat of harm, mental or emotional injury, or vulnerable adult has been subjected to abuse any kind of sexual contact or neglectconduct), or that a vulnerable adult has been subjected to self-neglectchild is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I file make a report with to the appropriate government governmental agency, usually the local office of the Department of Social Protective and Regulatory Services. Once such a report is filed, I may be required to provide additional information. • If I know determine that there is a patient has a propensity for violence and probability that the patient indicates that he/she has the intention to will inflict imminent physical injury on him/herself, or another, or that the patient will inflict imminent mental or emotional harm upon a specified victim(s)others, I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated action by disclosing information to eliminate the possibility that the patient will carry out the threat, seeking medical or law enforcement personnel or by securing hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and and, I will limit my disclosure to what is necessary. By signing this agreement, you authorize me to contact any person/entity in a position to prevent harm to the patient or a third party if I determine there is a probability of harm to the patient or a third party. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, complex and I am not an attorney. In situations where specific advice is required, formal legal advice consultation may be needed. Professional Records PROFESSIONAL RECORDS The laws and standards of the my profession require that I keep Protected Health Information (PHI) about each client you or your child in their clinical recordyour Clinical Record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It The Clinical Record includes information about you or your child's reasons for seeking therapy and how these and related issues impact on therapy, a description of the ways in which the problem impacts you or your child's life, your the diagnosis, the goals that we set for treatment, progress towards the those goals, your medical treatment and social history, treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would that have a right to a summary and to have their record been sent to another mental health provideranyone, including reports to your child's school. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep Except in some instances is a set of psychotherapy notes. These notes are for my own use and are designed unusual circumstances that involve danger to assist me in providing yourself and/or others, you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless Clinical Record if you request it in writing. You should be aware that pursuant to Texas law, psychological test data are not part of a patient's record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I determine recommend that knowledge you have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I charge a copying fee of the health care information would be injurious $.50 per page (and for certain other expenses). If I refuse your request for access to your healthrecords, you have a right of review, which I will discuss with you upon your request. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to clinical records your Clinical Record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your clinical record Clinical Record is discloseddisclosed to others; requesting an accounting of disclosuresmost disclosures of protected health information that you have neither consented to nor authorized; determining where the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this agreementAgreement, the attached Notice form, and my privacy policies and procedures, and the attached HIPAA notice form. Minors MINORS & Parents Parents of clients 16 PARENTS Patients under 18 years of age who are not emancipated from their parents should be aware that the law may be allowed by law allow parents to examine their child’s 's treatment records. While However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child's records. For children and adolescents, because privacy in psychotherapy is very importantoften critical in building rapport with the therapist, particularly with teenager, parental involvement which is also essential crucial to successful treatment. Thereforeprogress, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about discuss the progress of treatment manner in which I will communicate with his/her the son or daughter and the parents. Unless I feel discussing disclosure prior This discussion will typically take place early on in therapy so that all parties are informed as to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I how we will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents work together.
Appears in 1 contract
Samples: static1.squarespace.com
Limits of Confidentiality. The In general, the law protects the privacy of all communications between a patient client and a therapist/ psychologist. In most situations, I and we can only release information about your treatment to others if you sign with your written permission. But there are a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland law. However, in the following situations, no authorization is requiredfew exceptions: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If you are involved in a court proceeding under 18 years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is our policy to work with parents and a request is made children to resolve any issues regarding confidentiality. However we reserve the right to discuss issues with parents that are deemed necessary for information concerning your diagnosis and proper treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. There are some situations in which I am we are legally obligated to take actions, which I believe are necessary to attempt action to protect you and others from harm and I may harm, even if we have to reveal some information about a patient’s your treatment. These situations They are: ▪ If we feel you are unusual in my practice: danger of harming yourself, we will intervene to protect you by calling a family member or 911. ▪ If I we have reason to believe suspect that a child, adolescentan elderly person or a disabled person is being abused or neglected, or vulnerable adult has been subjected we are legally obligated to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government state agency. ▪ If we believe you are threatening serious bodily harm to another person, usually the local office of the Department of Social Services. Once such a report is filed, I may be required to provide additional information. If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be we are required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate notifying the possibility that potential victim, contacting the patient will carry out the threatpolice, or seeking hospitalization of the patient and/or informing the potential victim or the police about the threatfor you. ▪ If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on himare legal proceedings, your therapist/herself, or that immediate disclosure is required psychologist may be compelled to provide for the patient’s emergency health care needs, certain records of your treatment. Group Therapy Client Agreement – Signature Page Please initial: Notice of Privacy Practices Receipt _____ I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require acknowledge that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards have had the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports opportunity to insurance carriers or others. You may choose, in writing, to examine and/or receive review a copy of your clinical recordXxxxxxx CPS’s Notice of Privacy Practices (HIPAA). Because professional records can be misinterpreted it would be important I have read and understand the Group Therapy Client Agreement document and agree to first review them together abide by its terms. _________________________________________________ _________________ Signature of Patient or Guardian of Patient Date Consent for Treatment I hereby voluntarily consent to evaluation and/or treatment of myself or child by Xxxxxxx Counseling & Psychological Services, PLLC. I understand evaluation/treatment may include the use of psychiatric interviews, psychological tests, individual, family, or group counseling and/or therapy. I further understand my therapist/psychologist may consult with another mental health professionalother professionals at Xxxxxxx CPS in order to provide the best care possible for me or my family. In very unusual circumstances, such as a situation in which in At all times my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary privacy and to have their record sent to another mental health provider. A copying fee of $.60 per page care will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you treated with the best treatmenthighest regard. While the contents of Psychotherapy Notes vary from client to clientI have read, they can include the contents of our conservations, my analysis of those conversationsunderstand, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parentsforegoing. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.⇨⇨ Signature: ______________________________________________ Date: _____________
Appears in 1 contract
Samples: www.perkinscps.com
Limits of Confidentiality. The law protects the privacy of all communications between a therapist and patient. It protects any information that links back to you (identifiable patient and a psychologistinformation). In most situations, I can only release information about your treatment to others if you sign a consent form that meets certain legal requirements imposed written authorization for me to do so. There are some exceptions to this, which you will agree to by HIPAA and/or Maryland lawsigning this document. However, in the following situations, no authorization is requiredThese include: • I may occasionally find it helpful to consult with other health and mental health professionals about a case. During I also find it useful to have a consultationclinical supervisor whom I consult with on a regular basis. The purpose of this is to improve the services that I am giving you. With the possible exception of my clinical supervisor, I will make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound not disclose any information that may be traceable (identifiable) to keep the information confidentialyou. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work togetherconsultations. I will also note all specific consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices clinical record. • If a client threatens to Protect the Privacy of Your Health Information). Disclosures required by health insurers harm himself/herself, I may be obligated to seek hospitalization for him/her, or to collect overdue fees contact family members or others who can help provide protections. There are discussed elsewhere in this Agreement. some situations where I am permitted or required to disclose information without either your consent or authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentregarding the professional services that I have provided to you, such information is protected by the psychologistpsychotherapist-patient privilege law. I cannot provide any information without your written authorization, consent 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If I am providing treatment for conditions directly related to a worker’s compensation claim, I may have to submit such records, upon appropriate requests, to the Chairperson of the Worker’s Compensation Board on such forms and at such times as the chairperson may require. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm harm, and I may have to reveal some information about a patient’s treatment. These situations are unusual include: • If I receive information in my practice: If I have reason professional capacity that gives me reasonable cause to believe suspect that a child is an abused or neglected child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a me to report with to the appropriate government governmental agency, usually the statewide central registrar of child abuse and maltreatment and/or the local office of the Department of Social Serviceschild protective services office. Once such a report is filed, I may be required to provide additional information. • If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention communicated an immediate threat of serious physical harm to inflict imminent physical injury upon a specified victim(s)an identifiable victim, I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate notifying the possibility that potential victim, contacting the patient will carry out the threatpolice, or seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. • If such a situation one of these situations arises, I will make every effort to fully discuss it with you before taking any action action, and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove provide helpful in informing information to you about potential problems, it is important that we discuss any concerns or questions or concerns that you may have, have now or in the future. The laws governing regarding patient confidentiality can be are quite complex, and I am not an attorney. In ; in situations where specific advice is required, formal legal advice may be needed. Professional Records The laws law and standards of the my profession require that I keep Protected Health Information (PHI) about each client you in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about As the confidentiality of our therapy sessions is of the utmost importance, these records (electronic and printed are stored in a locked filing cabinet for your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports protection. Except in unusual circumstances where there is a danger to insurance carriers yourself or others. You , or where information has been provided to me confidentially by others, you may choose, in writing, to examine and/or receive a copy of your clinical record, if you request it in writing. Because professional records Copies are subject to my copy fee ($.25/page), and I require at least a one-week notice to fill this request. As these are clinical records, they can be misinterpreted it would be important and/or upsetting to first untrained readers. For this reason, I recommend that you initially review them together with me, or with have them forwarded to another mental health professionalprofessional so you can discuss the contents. In very unusual circumstancesIf I refuse your request for access to your records, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would you have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page review, which I will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing discuss with you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your healthupon request. Patient Rights HIPAA provides you with expanded several rights with regard to regarding your clinical records record and disclosures of protected health information. These rights require written request on your part, and include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosuresdisclosed to others; determining where the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this agreementagreement including the notice of my falling under the HIPAA laws, and my privacy policies and procedures, ; among others; and the attached right to submit a complaint to myself, HHS (related to HIPAA notice formcomplaints), or to through the NY State Office of Professions at <xxxx://xxx.xx.xxxxx.xxx/opd/complain.htm> . I am happy to discuss these rights, as well as any concerns or complaints, with you at any time. Minors & and Parents Parents Patients under the age of clients 16 years of age 18 who are not emancipated and their parents should be aware that the law may be allowed by law allow parents to examine their child’s treatment records. Even where parental consent has been given, children over age 12 may have the right to control access to their treatment records. While privacy in psychotherapy is very important, particularly with teenagerteenagers, parental involvement is also essential to successful treatment. ThereforeFor most children age 12 and over, it is your signature below represents an agreement between my policy when treating 16- patient and his/her parents allowing me to 18-year-olds to request that they agree to my sharing occasional share general information about the progress of the child’s treatment, including treatment with plans, and his/her parentsattendance at scheduled sessions. Unless I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s consent, unless I feel discussing disclosure prior to parental notification is not realistic, such as when that the child is in danger or is a danger to someone else, in which case I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, what I think if possible, and do my best to handle any objections or concerns he or she may have. In cases where the child is in their best interest under the age of 12, how open the therapy is will be discussed more thoroughly to discuss with meet the needs of the child. It is also important that you are aware that if the parents of a client under 18 are no longer together, both parents may have the right to review the client’s records. Please discuss any concerns you have about this with me. Billing and preferably both Payments You will be expected to pay for each session at the child time it is held, unless we agree otherwise. Payment for other professional services is due at the next session or on an otherwise agreed upon payment schedule. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. Please discuss this with me if you feel you are in need of this. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have 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 talk require me to disclose otherwise confidential information. In most collection situations, the only information necessary for me to release regarding a patient’s treatment is his/her name, the nature of the services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. Insurance/Reimbursement In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. I do not accept insurance payment at this time. This means that you are fully responsible for payment of my fees at the time of service. Please discuss any questions or concerns you have regarding fees with the parents together.me, either now or as they arise. Xxxxx Xxxxxxxx, LMFT Marriage and Family Therapy Psychotherapist-Patient Services Agreement YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE RECEIVED A COPY OF THE 5-PAGE PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT AND AGREE TO ITS TERMS: Signature/Printed: Date: Signature/Printed: Date: Signature/Printed: Date: Signature/Printed: Date: Witness: Date:
Appears in 1 contract
Samples: Services Agreement
Limits of Confidentiality. The law protects the privacy of all communications between a patient client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a consent form written Authorization for Release of Information that meets certain legal requirements imposed by HIPAA state law and/or Maryland lawHIPAA. However, in the following situationsthere are some situations where I am permitted or required to disclose information without either your consent or authorization: • If a client threatens to harm himself/herself, no authorization is required: I may be obligated to seek hospitalization for him/her, and/or to contact family members or others who can help provide protection (CA Evidence Code § 1024) • If a client communicates a serious threat of physical violence OR if a client’s family member reports that a client has made such a threat, I must take protective actions, including noticing the potential victim and contacting the police. I may also seek hospitalization of the client or contact others who can assist in protecting the victim (CA Evidence Code § 1024, CA Civil Code § 43.92). • Disclosures may be required to health insurers or to collections agencies to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patientclient. The other professionals are also legally bound to keep the information confidential. If you don’t n't object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice Record. • In cases of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers alleged criminal or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activitiescivil liability, I may be required court ordered to provide it for themrelease treatment information and/or records. If In addition, if a patient client files a complaint or lawsuit against me, I may disclose relevant information regarding that patient client in order to defend myself. There are some situations in which I am legally obligated • If a government agency is requesting the information for health oversight activities pursuant to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency, usually the local office of the Department of Social Services. Once such a report is filedtheir legal authority, I may be required to provide additional informationit for them. • If a client files a worker's compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker's compensation insurer. • I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/ children involved (CA Penal Code § 11164-11174.4; 288; 261-269, Child Abuse; CA Welfare and Institutions Code § 18951 ff.). • I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an elderly person or dependent adult to protect the elderly person or dependent adult involved (CA Welfare and Institutions Code § 15630 – 15632; § 15610 – 15610.65; § 15633 - 15637). • In couples or family treatment, please be aware that information shared with me will be disclosed to your partner or family if they are participating in treatment. I will not agree to hold secrets on any one partner's behalf. If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(syou feel something should not be shared with your partner, please do not tell me your secret(s). At such times, I it may be required most appropriate for you to take protective actions. These actions may include establishing seek the support of an individual therapist who is independent of your couple's treatment, and undertaking a treatment plan that is calculated to eliminate who will consult with me regarding the possibility that broad issues, and not the patient will carry out the threat, seeking hospitalization specifics of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessaryyour secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 1 contract
Samples: Services Agreement
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistpsychiatrist. In most situations, I can only release information about your treatment to others if you sign a consent written Authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPPA. HoweverThere are other situations that require only that you provide written, in the following situations, no authorization is requiredadvance consent. Your signature on this Agreement provides consent for those activities as follows: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychologistPsychiatrist’s Policies and Practices to Protect the Privacy of Your your Health Information). • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services that I provided you, such information is protected by the psychologistpsychiatrist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If I am providing treatment for conditions directly related to worker’s compensation claim, I may have to submit such records, upon appropriate request, to Chairman of the Worker’s Compensations Board on such forms and at such times as the chairman may require. There are some situations in which I am legally obligated obliged to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: . • If I have reason receive information in my professional capacity from a child or the parents or guardian or other custodian of a child that gives me reasonable cause to believe suspect that a child is an abused or neglected child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with to the appropriate government governmental agency, usually the statewide central register of child abuse and maltreatment, or the local office of the Department of Social Serviceschild protective services office. Once such a report is filed, I may be required to provide additional information. • If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention communicates an immediate threat of serious physical harm to inflict imminent physical injury upon a specified victim(s)an identifiable victim, I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate notifying the possibility that potential victim, contacting the patient will carry out the threatpolice, or seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records PROFESSIONAL RECORDS The laws and standards standard of the my profession require that I keep Protected Health Information (PHI) about each client you in their clinical recordyour Clinical Record. In some circumstances, I may keep some Except in unusual circumstances that involve danger to yourself and/or others or where information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal has been supplied to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical recordconfidentially by others, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I determine recommend that knowledge you initially review them in my presence, or have them or have them forwarded to another mental health professional so you can discuss the contents. I am allowed to charge a copy fee of the health care information would be injurious 75 cents per page (and for certain other expenses). If I refuse your request for access to your healthrecords, you have a right to review, which I will discuss with you upon request. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to clinical records your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your clinical record Clinical Records is discloseddisclosed to others; requesting an accounting of disclosuresmost disclosures of protected health information that you have neither consented to not authorize; determining where the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this agreementAgreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. (In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.) If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have 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 me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the attached HIPAA notice formamount due. Minors & Parents Parents of clients 16 years of age who are not emancipated may (If legal action is necessary, its costs will be allowed by law included in the claim.) INSURANCE REIMBURSEMENT In order for us to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Thereforeset realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy when treating 16- to 18-year-olds to request covers. You should carefully read the section in your insurance coverage booklet that they agree to my sharing occasional general information describes mental health services. If you have questions about the progress of treatment with his/her parentscoverage, call your plan administrator. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone elseOf course, I will discuss provide you with whatever information I can based on my experience and will be happy to help you in understanding the childinformation you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. (Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in our computer. Though all insurance companies claim to keep such information confidential, I have no control over what I think they do with it once it is in their best interest to discuss hands. In some cases, they may share the information with the parents and preferably both the child and national medical information database. I will talk provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the parents together.benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above (unless prohibited by contract). YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. _ _ Patient Signature Witness
Appears in 1 contract
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistbehavioral health treatment provider. In most situations, I PBHP can only release information about your treatment to others if you sign a consent written authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland Illinois law. However, in the following situations, no authorization is required: I A PBHP treatment provider may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I your treatment provider will make every effort to avoid revealing the identity of my patientyour identity. The other professionals are also legally bound to keep the information confidential. If you don’t do not object, I your provider will not tell you about these consultations unless I feel that he/she feels it is important to our your work together. I Your provider will note all consultations in your Clinical Record (which is called referred to as “PHI” in my the Notice of Psychologist’s Palos Behavioral Health Professionals’ Policies and Practices to Protect the Privacy of Your Health Information). You should be aware that your PBHP treatment provider practices with other mental health professionals and that PBHP employs administrative staff. In most cases, your treatment provider will need to share protected information with these individuals for both clinician and administrative purposes, such as scheduling, billing, and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege lawMental Health and Developmental Disabilities Confidentiality Act. I PBHP cannot provide disclose any information without your written authorization, or a court order. If you are involved in or are contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me your treatment provider to disclose information. If a government agency is requesting the information for health oversight activities, I PBHP may be required to provide it for them. If a patient files a complaint or lawsuit against mea treatment provider, I that treatment provider may disclose relevant information regarding that patient in order to defend myselfprovide defense. If you file a worker’s compensation claim, and your treatment provider is rendering treatment or services in accordance with the provisions of the Illinois Workers’ Compensation law, the treatment provider must, upon appropriate request, provide a copy of your record to your employer or his/her appropriate designee. There are some situations in which I am a PBHP treatment provider is legally obligated to take actions, which I believe are action that the treatment provider believes is necessary to attempt to protect others from harm and I harm. To this end, the treatment provider may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason a PBHP treatment provider has reasonable cause to believe that a child under 18 years may be, in the providers’ professional capacity, an abused or neglected child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I the provider file a report with the appropriate government agency, usually the local office of the Department of Social Children and Family Services. Once such a report is filed, I the provider may be required to provide additional information. If I know a PBHP treatment provider has reason to believe that an adult over 60 years is living in a patient domestic situation and has been abused or neglected in the preceding 12 months, the law requires that the provider file a propensity for violence and report with the patient indicates that he/she has agency designated to receive such reports by the intention to inflict imminent physical injury upon Department of Aging. Once such a specified victim(s)report is filed, I the provider may be required to provide additional information. If you have made a specific threat of violence against another or if your PBHP treatment provider believes that you present and clear, imminent risk of serious physical harm to another, the provider may be required to disclose information in order to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing notifying the potential victim victim, contacting the police, or the police about the threatseeking your hospitalization. If I believe your PBHP treatment provider believes that there is an you present a clear, imminent risk that a patient will inflict of serious physical harm or mental injury or death on him/herselfto yourself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I provider may be required to disclose information in order to take appropriate protective actions, including initiating hospitalizations and/or notifying . These actions may include seeking your hospitalization or contacting family members or others who can protect assist in protecting you. Currently, a new law in Illinois requires all healthcare providers to report persons deemed unstable to the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessaryFirearms Owner Identification program (FOID) so that possible use of firearms in situations like school shootings can be prevented. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we you and your treatment provider discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am PBHP treatment providers are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 1 contract
Samples: Outpatient Services Agreement
Limits of Confidentiality. The In general, the law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment can only be released to others if you sign a consent written Authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. HoweverThere are other situations that require only that your provide written, in the following situationsadvance consent. Your signature on this Agreement provides consent for those activities, no authorization is requiredas follows: I • Therapists may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I therapists make every effort to avoid revealing the identity of my patienttheir client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I clients will not tell you be advised about these consultations unless I feel the therapist feels that it is important to our your work together. I All consultations will note all consultations be documented in your Clinical Record (which is called “PHI” in my “Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information”). Disclosures • You should be aware that the Counseling Center employs an assistant. In most cases, therapists need to share protected information with the assistant for administrative purposes, such as schedules. All of the mental health professionals are bound by the same rules of confidentiality. The assistant has been trained about protecting your privacy and has agreed not to release any information outside of the Center without the permission of a professional staff member. There are some situations where therapists are permitted or required by health insurers to disclose information without either your consent or to collect overdue fees are discussed elsewhere in this AgreementAuthorization. • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I Mental health professionals cannot provide any information without (or your 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 your therapist to disclose information. • If a government agency is requesting the information for health oversight activities, I your therapist may be required to provide it for them. • If a patient client files a complaint or lawsuit against mehis/her therapist, I the therapist may disclose relevant information regarding that patient client in order to defend myselfhim/her. • If a client files a worker’s compensation claim related to the services the therapist is providing, the therapist may, upon appropriate request, disclose protected information to others authorized to receive it by the workers’ compensation law. There are some situations in which I am mental health professionals are legally obligated to take actions, which I they believe are necessary to attempt to protect others from harm and I they may have to reveal some information about a patientclient’s treatment. These situations are unusual in my the Counseling Center practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency, usually the local office of the Department of Social Services. Once such a report is filed, I may be required to provide additional information. If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 1 contract
Samples: Counseling Center Agreement
Limits of Confidentiality. The law protects the privacy of all communications between a patient client and a psychologist. In most situations, I we can only release information about your treatment to others only if you sign a consent written Authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. HoweverThere are other situations that require only that you provide written, in the following situationsadvance consent. Your signature on this Agreement provides consent for those activities, no authorization is requiredas follows: I • We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my the patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel that it is important to our work together. I We will note all consultations in your Clinical Record. • We may access your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect with an appropriate purpose including but not limited to, documenting the Privacy of Your Health Information)patient's treatment, billing insurance; conducting peer review or quality assurance activity, supervision, or for a purpose expressly authorized by the patient. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where we are permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient client privilege law. I We cannot provide any information without your 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 your therapist to disclose information. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a patient client files a complaint or lawsuit against meus, I we may disclose relevant information regarding that patient client in order to defend myselfourselves. • If we are being compensated for providing treatment to you as a result of your having filed a worker’s compensation claim or through an automobile insurance plan, we must, upon appropriate request, provide information necessary for utilization review purposes. There are some situations in which I am we are legally obligated to take actions, actions which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my our practice: . • If I we have reason reasonable cause to believe that a child, adolescent, or vulnerable adult has been subjected to suspect child abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I we file a report with the appropriate government agency, usually the local office of the Department of Social ServicesFamily Independence Agency. Once such a report is filed, I we may be required to provide additional information. • If I know that we have reasonable cause to suspect the “criminal abuse” of an adult client, we must report it to the police. Once such a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s)report is filed, I we may be required to provide additional information. • If a client communicates a threat of physical violence against a reasonably identifiable third person and the client has the apparent intent and ability to carry out that threat in the foreseeable future, we may have to disclose information in order to take protective actionsaction. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing notifying the potential victim or (or, if the police about victim is a minor, his/her parents and the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herselfcounty Department of Social Services) and contacting the police, or that immediate disclosure is required to provide and/or seeking hospitalization for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patientclient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 1 contract
Samples: Service Agreement
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistmental health professional. In most situations, I we can only release information about your treatment to others if you sign a consent written authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. HoweverThere are situations that require only that you provide written, in the following situations, no authorization is requiredadvance consent. Your signature on this Agreement provides consent for those activities as follows: I We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my our patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel that it is important to our work together. I We will note all consultations in your Clinical Record clinical record (which is called “PHI” in my our Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures There are some situations where we are permitted or required by health insurers to disclose information without either your consent or to collect overdue fees are discussed elsewhere in this Agreement. Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologistclinician-patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, 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 us to disclose information. If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. If a patient files a complaint or lawsuit against mehis/her clinician, I that clinicians may disclose relevant information regarding that patient in order to defend myselfthemselves. There are some situations in which I am we are legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my our practice: . If I we have reason cause to believe that a childchild under 18 has been or may be abused or neglected (including physical injury, adolescentsubstantial threat of harm, mental or emotional injury, or vulnerable adult has been subjected to abuse any kind of sexual contact or neglectconduct), or that a vulnerable adult has been subjected to self-neglectchild is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I file we make a report with to the appropriate government governmental agency, usually the local office of the Department of Social Family Protective Services. Once such a report is filed, I we may be required to provide additional information. If I know we determine that there is a patient has a propensity for violence and probability that the patient indicates that he/she has the intention to will inflict imminent physical injury on another, or that the patient will inflict imminent physical, mental or emotional harm upon a specified victim(s)himself/herself, I or others, we may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated action by disclosing information to eliminate the possibility that the patient will carry out the threat, seeking medical or law enforcement personnel or by securing hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. However, in cases that involve child abuse, Section 611 of the Texas Health and Safety laws allows for clinicians to refuse to disclose information to a parent who may pose substantial harm to a child either physically or emotionally. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we you discuss any questions or concerns that you may have, have now or in the futurefuture with your psychologist/therapist. The laws governing confidentiality can be quite complex, and I am the clinicians at MOCE are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, MOCE clinicians keep Protected Health Information (PHI) PHI about each client you in their clinical recordprofessional progress records which are collectively referred to as your Clinical Record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It Your Clinical Record includes information about your reasons for seeking therapy and how these and related issues impact therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards the those goals, your medical treatment and social history, your treatment history, any past treatment records I that we receive from other providers, reports of any professional consultations, your billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would that have a right to a summary and to have their record been sent to another mental health provideranyone, including reports to your insurance carrier. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep Except in some instances is a set of psychotherapy notes. These notes are for my own use unusual circumstances that involve danger to yourself and are designed to assist me in providing others, you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine Clinical Record if you request it in writing. You should be aware that knowledge pursuant to Texas law, psychological test data are not part of a patient’s record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in the presence of your MOCE clinician, or have them forwarded to another mental health care information would be injurious professional so you can discuss the contents. Clinicians are sometimes willing to conduct this review meeting without charge. In most circumstances, MOCE is allowed to charge a copying fee of $1.00 per page to cover supply and administrative costs. If your request for access to your healthClinical Record is refused, you have a right of review, which your clinician or the MOCE Privacy Officer will discuss with you upon your request. Patient Rights HIPAA provides Clinical records are kept electronically via a secure and encrypted online service. If you with expanded rights with regard have any question about the protection of your records please feel free to clinical records and disclosures of protected health information. These include requesting that I amend ask your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and therapist or the right to a paper copy of this agreementMOCE Privacy Officer, my policies and procedures, and the attached HIPAA notice formXxxxx Xxxxx. Minors & Parents Parents of clients 16 Patients under 18 years of age who are not emancipated and their parents should be aware that the law may be allowed by law allow parents to examine their child’s treatment records. While However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child’s records. For children between 16 and 18, because privacy in psychotherapy is very importantoften crucial to successful progress, particularly with teenagers, this can lead to a potential problem in therapy. The clinician must work very diligently to maintain a balance between a teenagers’ felt need for privacy/confidentiality and a parent’s right to access their child’s records. All therapists will work prudently with their clients to find that balance for the good of the teenager, parental involvement is also essential to successful treatment. Therefore, unless it is my policy when treating 16- to 18-year-olds to request determined that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child client is in danger or is a danger to someone else, I in which case, we will discuss with notify the childparents immediately of our concern. BILLING & PAYMENTS You will be expected to pay for each session at the time it is held, what I think unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. You will not be seen by your therapist when your account is in their best interest arrears three sessions, unless some prior arrangement has been made between yourself and the therapist. INSURANCE REIMBURSEMENT In order for us to discuss set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. We will fill out forms and provide you with whatever assistance we can in helping you receive the parents benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, MOCE will provide you with whatever information we can based on our experience and preferably both will be happy to help you in understanding the child and I information you receive from your insurance company. If it is necessary to clear confusion, we will talk with be willing to call the parents togethercompany on your behalf.
Appears in 1 contract
Samples: 0201.nccdn.net
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistpsychiatrist. In most situations, I can only release information about your treatment to others if you sign a consent written Authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPPA. HoweverThere are other situations that require only that you provide written, in the following situations, no authorization is requiredadvance consent. Your signature on this Agreement provides consent for those activities as follows: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychologistPsychiatrist’s Policies and Practices to Protect the Privacy of Your your Health Information). You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services that I provided you, such information is protected by the psychologistpsychiatrist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. If I am providing treatment for conditions directly related to worker’s compensation claim, I may have to submit such records, upon appropriate request, to Chairman of the Worker’s Compensations Board on such forms and at such times as the chairman may require. There are some situations in which I am legally obligated obliged to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: . If I have reason receive information in my professional capacity from a child or the parents or guardian or other custodian of a child that gives me reasonable cause to believe suspect that a child is an abused or neglected child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with to the appropriate government governmental agency, usually the statewide central register of child abuse and maltreatment, or the local office of the Department of Social Serviceschild protective services office. Once such a report is filed, I may be required to provide additional information. If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention communicates an immediate threat of serious physical harm to inflict imminent physical injury upon a specified victim(s)an identifiable victim, I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate notifying the possibility that potential victim, contacting the patient will carry out the threatpolice, or seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records PROFESSIONAL RECORDS The laws and standards standard of the my profession require that I keep Protected Health Information (PHI) about each client you in their clinical recordyour Clinical Record. In some circumstances, I may keep some Except in unusual circumstances that involve danger to yourself and/or others or where information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal has been supplied to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical recordconfidentially by others, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I determine recommend that knowledge you initially review them in my presence, or have them or have them forwarded to another mental health professional so you can discuss the contents. I am allowed to charge a copy fee of the health care information would be injurious 75 cents per page (and for certain other expenses). If I refuse your request for access to your healthrecords, you have a right to review, which I will discuss with you upon request. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to clinical records your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your clinical record Clinical Records is discloseddisclosed to others; requesting an accounting of disclosuresmost disclosures of protected health information that you have neither consented to not authorize; determining where the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this agreementAgreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. (In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.) If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have 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 me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the attached HIPAA notice formamount due. Minors & Parents Parents of clients 16 years of age who are not emancipated may (If legal action is necessary, its costs will be allowed by law included in the claim.) INSURANCE REIMBURSEMENT In order for us to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Thereforeset realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy when treating 16- to 18-year-olds to request covers. You should carefully read the section in your insurance coverage booklet that they agree to my sharing occasional general information describes mental health services. If you have questions about the progress of treatment with his/her parentscoverage, call your plan administrator. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone elseOf course, I will discuss provide you with whatever information I can based on my experience and will be happy to help you in understanding the childinformation you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. (Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in our computer. Though all insurance companies claim to keep such information confidential, I have no control over what I think they do with it once it is in their best interest to discuss hands. In some cases, they may share the information with the parents and preferably both the child and national medical information database. I will talk provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the parents together.benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above (unless prohibited by contract). YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. _______________________________ _____________________________________ Patient Signature Witness _______________________________ ______________________________________
Appears in 1 contract
Limits of Confidentiality. The law protects It is important that you understand the privacy laws of the State of Texas and all communications between a patient and a psychologistexceptions to confidentiality. In most certain situations, I can only release information about your treatment to others if you sign a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland law. However, in the following situations, no authorization is required: I may occasionally find it helpful to consult other health and mental health professionals are required by law to reveal information obtained during therapy to other persons or agencies without your permission. This includes the following: • Confidentiality does not apply to cases of suspected abuse/neglect of children under the age of 18 by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare. • Confidentiality does not apply to cases of suspected abuse/neglect of a vulnerable adult (disabled, elderly, etc.) • Confidentiality does not apply to cases of potential harm to self, to others, or to society. • A mental health professional may disclose confidential information in proceedings brought by a client against a professional. • Confidentiality may not apply in cases involving legal proceedings affecting the parent-child relationship, including subpoenas to testify in court, or court-ordered to disclose confidential information • Confidentiality may not apply to cases involving the minor child. In such cases, the counselor may advise a parent, managing conservator, or guardian of a minor, with or without the minor’s consent, of the treatment needed by or given to the minor. For additional information about a case. During a consultationprivacy, I make every effort to avoid revealing confidentiality, and the identity limitations of my patient. The other professionals are also legally bound to keep the information confidentialconfidentiality, please review Healing Minds Behavioral Health, PLLC’s Notice of Privacy Practices. If you don’t objector your child has any questions regarding confidentiality, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report please discuss them with the appropriate government agency, usually the local office of the Department of Social Services. Once such a report is filed, I may be required to provide additional information. If I know Licensed Professional Counselor so that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns can be addressed. Consent Regarding Electronic Medical Records: Healing Minds Behavioral Health currently uses Simple Practice software to maintain electronic health records for all clinical services provided. For clients with existing records that are disclosed and provided to Healing Minds Behavioral Health, they will be scanned and stored electronically as well. Passwords to access client records are not shared with anyone outside of the organization for any reason. Court Disclaimer: Healing Minds Behavioral Health counselors will not have any therapeutic involvement in any ongoing custody cases or cases that may lead to civil court hearings for the purposes of determination of custody. Texas Family Code 104.008 prohibits our testimony and does not allow us to offer an expert opinion or recommendation to the conservatorship of or possession of or access to a child at issue in a suit unless we have conducted a child custody evaluation relating to the child. We are NOT custody evaluators, nor can we assume that dual role if you may have, now have chosen us to be the therapist for you or your child. We will be happy to provide a referral to a forensic counselor and we will remain out of the court room. Subpoenas: Please refer to the fee schedules found below to see all applicable fees in the futureevent that a subpoena is issued. Please note that your signature on this document is considered to be consent by you to pay all fees billed to you that are related to court costs (i.e. travel, copying of records, clinical summaries, securing of attorney/legal consultation, etc.) regardless of whether or not you initiated the court proceedings. The laws governing confidentiality can be quite complex, subpoena fee is in addition to the counseling service fees outlined in our document titled “New Client Intake and I am not an attorneyFinancial Agreement”. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require Please note that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would this fee will not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While covered by insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents togetherpayers.
Appears in 1 contract
Samples: Counseling Agreement
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a consent written Authorization to Release Information form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. HoweverThere are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: ● If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. ● If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm themselves, I may be obligated to seek hospitalization for them or to contact family members or others who can help provide protection. If a similar situation occurs in the following situationscourse of our work together, no authorization is required: I will attempt to fully discuss it with you before taking any action. ● I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals professions are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Psychologist Policies and Practices to Protect the Privacy of Your Health Information). Disclosures ● You should be aware that I may employ administrative staff. In those cases, I will need to share protected information with those individuals for administrative purposes, such as billing and quality assurance. All staff members will be trained about protecting your privacy and will agree not to release any information outside of the practice without my permission. There are some situations where I am permitted or required by health insurers to disclose information without either your consent or to collect overdue fees Authorization. They are discussed elsewhere in this Agreement. as follows: ● If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (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 where a court would be likely to order me to disclose information. ● If a government agency the Alabama Board of Examiners in Psychology is requesting the information for health oversight activitiesan investigation of my practice, I may be am required to provide it for them. ● If a patient files a complaint compliant or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. ● If a patient files a worker’s compensation claim, I may disclose information relevant to that claim to the patient’s employer or the insurer. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm harm, and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: ● If I have reason to believe know or suspect that a child, adolescent, or vulnerable adult child under the age of 19 has been subjected to abuse abused or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitationneglected, the law requires that I file a report with the appropriate government agency, usually the local office of the Alabama Department of Social ServicesHuman Resources. Once such a report is filed, I may be required to provide additional information. ● If I know or suspect that an elderly or disabled adult has been abused, neglected, exploited, sexually, emotionally, or physically abused, the law requires that I file a patient has a propensity for violence and report with the patient indicates that he/she has appropriate governmental agency, usually the intention to inflict imminent physical injury upon a specified victim(s)Alabama Department of Human Resources. Once such report is filed, I may be required to take protective actionsprovide additional information. These actions ● If I believe that disclosing information about you is necessary to prevent or lessen a serious and imminent threat to the health and safety of an identifiable person(s), I may include establishing and undertaking a treatment plan disclose that is calculated information, but only to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim those reasonably able to prevent or the police about lessen the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arisesone of these situations arise, I will make every effort to fully discuss it with you before taking any action action, and I will try to limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws PATIENT’S RIGHTS HIPAA provided you with several new or expanded rights with regard to your Clinical Record and standards disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the profession require that location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information form, and my privacy policies and procedures. I will be happy to discuss any of these rights with you. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information you in two sets of professional records. One set is constitutes your clinical recordClinical Record. It includes information about your reasons for seeking therapy and how these and related issues impact on therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards the those goals, your medical treatment and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, test results, and any reports that have been sent to anyone, including reports to your insurance carriers or otherscarrier. You may chooseIf you provide me with an appropriate written request, in writing, you have the right to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important for a fee, except in unusual circumstances that involve danger to first review them together you or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be releasedothers. In those situations, the person would you have a right to a summary and to have their your record sent to another mental health provider. A copying fee The exceptions to this policy are contained in the attached Notice of $.60 per page Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information form. If I refuse your request for access to your records, you have a right of review, which we will be chargeddiscuss with you upon request. There In addition, I may be other associated costs for review of records. The other set I also keep in some instances is a set of psychotherapy notesPsychotherapy Notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client patient to clientpatient, they can include the contents of our conservationsconversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical recordClinical Record. These psychotherapy notes Psychotherapy Notes are kept separate from your clinical recordClinical Record. While insurance companies can request and receive a copy of your clinical recordClinical Record, they cannot receive a copy of your psychotherapy notes Psychotherapy Notes without your signed, written authorizationAuthorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal. You If I die or become incapacitated, there is a probability that a designated Professional Executor may examine take control of patient’s records and contact them. PROFESSIONAL FEES My fee for the initial consultation is $187.00. Sessions lengths can vary. Sessions between 16 and 37 minutes are billed at $93.00. Sessions between 38 and 52 minutes are billed at $140.00. Sessions over 52 minutes are billed at $187.00. Additional fees may be applied for additional services and interactive complexity, such as brief consultation with family members. Most insurances and managed care organizations require a co-pay and/or receive a copy deductible for which you are responsible. If you are using your insurance, you are responsible for verification of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious coverage and for obtaining pre-authorization for these services prior to your healthfirst visit. Patient Rights HIPAA provides OTHER FEES If we meet more than the usual time, I will charge accordingly. In addition to weekly appointments, I charge this same hourly rate for other professional services you may need, though I will prorate the hourly cost if I work for periods of less than one hour. Other professional services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with expanded rights with regard to clinical records and disclosures other professionals you have authorized, preparation of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedurestreatment summaries, and the attached HIPAA notice formtime spent performing any other service you may request of me. Minors & Parents Parents If a check is returned, the returned check fee is $30.00. Any court appearance, or deposition, or the provision of clients 16 years documents for any attorney or for the court will be billed at a rate of age who $200 per hour, and will include preparation and travel time. You will be responsible for all such fees related to your evaluation or treatment, payable at the time any such court-related services are not emancipated may requested. The fee for Medical/Mental Health Records or written communications to you or on your behalf will be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress a minimum of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents $20 and preferably both the child and I will talk with the parents togethercan increase depending on time spent.
Appears in 1 contract
Samples: Patient Agreement
Limits of Confidentiality. The law protects the privacy of all communications between a patient client and a psychologist. In most situations, I we can only release information about your treatment to others only if you sign you’ve signed a consent written authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. HoweverThere are other situations that require only that you provide written, in the following situationsadvance consent. Your signature on this agreement provides consent for those activities, no authorization is requiredas follows: I ● We may occasionally find it helpful to consult other health and mental health professionals about a the case. During a consultation, I we make every effort to avoid revealing the identity of my the patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel that it is important to our work together. I We will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychologistRecord. ● We may access your clinical record with an appropriate purpose including but not limited to, documenting the patient’s Policies and Practices to Protect treatment, billing insurance; conducting peer review or quality assurance activity, supervision, or for a purpose expressly authorized by the Privacy of Your Health Information)patient. ● Disclosures are required by health insurers or to collect overdue fees are discussed elsewhere in this Agreementagreement. ● If a client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where we are permitted or required to disclose information without either your consent or Authorization: ● If you are involved in a court proceeding and in a request is made for information Information concerning your diagnosis and treatment, such information is protected by the psychologist-patient psychologist – client privilege lawlog. I We cannot provide any information without your 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 quart will be likely to order me your therapist to disclose information. Ent information concerning your diagnosis and treatment, such information is protected by the psychologist Dash client privilege law. We cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a quart will be likely to order your therapist to disclose information. ● If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. ● If a patient client files a complaint or lawsuit against meus, I we may disclose relevant information regarding that patient the client in order to defend myselfourselves. ● If we are being compensated for providing treatment to you as a result of you having filed a Worker’s Compensation claim or through an automobile insurance plan, we must, Upon appropriate request, provide information necessary for utilization review pre upon appropriate request, provide information necessary for utilization review purposes. There are some situations in which I am we are legally obligated to take actions, action which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These Do you situations are unusual in my our practice: . ● If I we have reason reasonable cause to believe that a child, adolescent, or vulnerable adult has been subjected to suspect child abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I we file a report with the appropriate government agency, usually the local office of the Department of Social ServicesFamily Independence Agency. Once such a report is filed, I we may be required to provide additional information. ● If I know that we have a patient has reasonable cause to suspect the “criminal abuse“ of an adult client, we must report it to the police. Once such a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s)report is filed, I we may be required to provide additional information. ● If a client communicates a threat of physical violence against a reasonably identifiable third person and the client has the apparent intent and ability to carry out that threat in the foreseeable future, we may have to disclose information in order to take protective actionsaction. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing notifying the potential victim or (or, if the police about victim is a minor, his/her parents and the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herselfcounty Department of Social Services) and contacting the police, or that immediate disclosure is required to provide and/or seeking hospitalization for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patientclient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I You should be aware that, pursuant to HIPAA, We keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in you and two sets of professional records. One set is constitutes your clinical recordClinical Record. It includes information about your reasons for seeking therapy and how these and related issues impact therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards the these goals, your medical treatment and social history, past your treatment history, and he passed treatment records I receive that we received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carriers carrier. Except in unusual circumstances where disclosure would physically in danger you and/or others or others. You makes reference to another person (unless such other person is a healthcare provider) and we believe that access is reasonably likely to cause substantial harm to such other person, you may choose, in writing, to examine and/or receive a copy of your clinical recordClinical Record If you request it in writing. Because these are professional records records, they can be misinterpreted it would be important and/or upsetting to first untrained readers. For this reason, We recommend that you initially review them together in the presence of your therapist, or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent them forwarded to another mental health providerprofessional so you can discuss the contents. A In most circumstances, we are allowed to charge a copying fee of $.60 1 per page will be charged. There may be other associated costs for review of recordspage. The other set I exceptions to this policy are contained in the attached Notice. If we refuse your request for access to your Clinical Records, do you have a right of review (except for information supplied to us confidentially by others), which we will discuss with you upon request. In addition, we also keep in some instances is a set of psychotherapy notesPsychotherapy Notes. These notes are for my our own use and are designed to assist me us in providing you with the best treatment. While the contents of Psychotherapy Notes vary very from client to client, they can include the contents of your conversations with your therapist, our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me review that is not required to be included in your clinical recordClinical Record. They also include information from others provided to me confidentially. These psychotherapy notes Psychotherapy Notes are kept separate from your clinical recordClinical Record. While insurance companies can request Your Psychotherapy Notes are not available to you and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes be sent to anyone else, including insurance companies, without your signedwritten, written signed authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way anyway for your refusalrefusal to provide it. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Client Rights HIPAA provides you with several new or expanded rights with regard regards to clinical records your Clinical Records and disclosures of protected health information. These rights include requesting that I we amend your record; requesting restrictions on what information from your clinical record is disclosedClinical Records Is disclosed to others; requesting an accounting of disclosuresmost disclosures of protected health information that you have neither consented to North authorized; determining where the location to which protected information disclosures are sent; having any complaints you make about my our policies and procedures recorded in your records; and the right to a paper copy of this agreement, my the attached notice, and our privacy policies and procedures. We’re happy to discuss any of these rates is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to North authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached notice, and the attached HIPAA notice formour privacy policies and procedures. We’re happy to discuss any of these rights with you. Minors & and Parents Parents of clients 16 Clients under 18 years of age who are not emancipated and their parents should be aware that the law may be allowed by law allow parents to examine their child’s treatment records. They should also be aware that patients over 14 years of age can consent to (and control access to information about) . their own treatment, although that treatment cannot extend beyond 12 sessions or four months. While privacy in and psychotherapy is very important, particularly with teenagerteenagers, parental involvement is also essential to successful treatment. Therefore, it is my usually our policy when treating 16- to 18-year-olds to request that they agree an agreement from any client between 14 and 18 and his/her parents allowing us to my sharing occasional share general information with parents about the progress of treatment with his/her parentsand the child’s attendance at scheduled sessions. Unless I feel discussing disclosure prior to parental notification is not realisticBefore giving parents any information, such as when the child is in danger or is a danger to someone else, I we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. Billing and Payments (We ask that you pay for each session at the time it is held. If there have been no payments to your account for more than 45 days and arrangements for payment have not been agreed-upon, we have 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 us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a client’s treatment is his/her name, the nature of the services provided, and the amount due. If such legal action is necessary, it’s costs will be included in the claim). Insurance Reimbursement In order for us to set realistic treatment goals and priorities, it is important to evaluate what I think resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled. However, you (not your insurance company) are responsible for full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you and understanding the information you received from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf. You should also be aware that your contract with your health insurance company requires that we provided with information relevant to the services that we provide you. We are required to provide A clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies going to keep such information confidential, we have no control over what they will do with it once it is in their best interest hands. In some cases they may share information with a national medical information data bank. Will provide you with a copy of any report we submit, if you requested. By signing this agreement, you agree that we can provide requested information to discuss with the parents and preferably both the child and I will talk with the parents togetheryour carrier.
Appears in 1 contract
Samples: Healthy Living Psychology Group
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistpsychologist or mental health counselor. In most situations, I we can only release information about your treatment to others if you sign a consent written Authorization form that meets certain legal requirements imposed by HIPAA state law and/or Maryland lawHIPAA. HoweverBut, there are some situations where we am permitted or required to disclose information without either your consent or Authorization. We may find it helpful and that it be in the following situationsyour best interest to consult with your physician, no authorization is required: I may psychiatrist or other professional to coordinate your treatment.We occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my patient. client’s identity.The other professionals are also legally bound to keep the any information we share confidential. If Unless you don’t object, I we will not tell you about these consultations unless I we feel that it is important to our work together. I .We will note all consultations in your Clinical Record (which is called “PHI” Record. We practice in my Notice a group setting with several mental health professionals and we employ administrative staff. In most cases, we share protected information among these individuals for both clinical supervision and administrative purposes, such as scheduling, billing and to ensure that all of Psychologist’s Policies our clients receive the highest possible quality of care. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and Practices have agreed not to Protect release any information outside of the Privacy of Your Health Information)practice. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreementbelow. If a client threatens to harm him or herself, we may be obligated to seek hospitalization for him or her, or to contact family members or others who can help provide protection. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentabout the professional services that we have provided you and/or the records thereof, such information is protected by the psychologistpsychotherapist-patient client privilege law. I We cannot provide any information without your (or your legally appointed representative’s) written authorization, or a court order, or compulsory process (a subpoena)or discovery request from another party to the court proceeding where that party has given you proper notice (when required) and has stated valid legal grounds for obtaining PHI, and we do not have grounds for objecting under state law (or you have instructed me not to object). 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 government agency is requesting the information for health oversight activitiesactivities pursuant to their legal authority, I we may be required to provide it for them. them If a patient client files a complaint or lawsuit against meus, I we may disclose relevant information regarding that patient client in order to defend myselfourself. If a client files a worker’s compensation claim, we must, upon appropriate request, disclose information relevant to the claimant's condition, to the worker’s compensation insurer. There are some situations in which I am we are legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patientclient’s treatment. .These situations are unusual highly rare in my our practice: . If I we have reason reasonable cause to believe suspect that a childchild under 18 is abused or neglected, adolescentthe law requires that we file a report with the appropriate governmental agency, usually Department of Public Health and Human Services. Once such a report is filed, we may be required to provide other information. If we know or vulnerable adult have reasonable cause to suspect that an older person or person with a developmental disability has been subjected to abuse or neglectabuse, or that a vulnerable adult has been subjected to self-sexual abuse, neglect, or exploitation, the law requires that I we file a report with the appropriate government governmental agency, usually the local office of the Department of Social Public Health and Human Services. Once such a report is filed, I we may be required to provide additional information. If I know that a patient has client communicates an actual threat of immediate threat of physical violence by specific means against a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s)clearly identified or reasonably identifiable victim, I we may be required to take protective actions. disclose protected information in order to protect the threatened victim.These actions may include establishing and undertaking a treatment plan that is calculated to eliminate notifying the possibility that potential victim, contacting the patient will carry out the threatpolice, or seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patientclient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. .The laws governing confidentiality can be quite complex, and I am not an attorney. In in situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I You should be aware that, in accordance with HIPAA laws, we keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information you in two sets of professional records. One set is constitutes your clinical recordClinical Record. It includes information about your reasons for seeking therapy and how these and related issues impact therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards the those goals, your medical treatment and social history, your treatment history, any past treatment records I that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professionalcarrier. In very unusual circumstancesaddition, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I we also keep in some instances is a set of psychotherapy notes. Psychotherapy Notes.These notes Notes are for my our own personal use and are designed to assist me us in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can may include the contents of our conservations, my conversations and our analysis of those conversations, and how they impact on your therapy. .They also may contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. Clinical Record.These psychotherapy notes Psychotherapy Notes are kept separate from your clinical record. Clinical Record.While insurance companies can request and receive a copy of your clinical recordClinical Record, they cannot receive a copy of your psychotherapy notes Psychotherapy Notes without your signed, written authorizationAuthorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal. You xxxxxxx.Xxx may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge both sets of records if you request it in writing, except for information provided by an individual (other than another health care provider) in confidence under circumstances in which confidentiality was appropriate and the access requested would be reasonably likely to reveal the source of the information. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in your psychotherapist’s presence, or have them forwarded to another mental health professional so you can discuss the contents.We charge a copying fee not to exceed 50 cents per page, and an administrative fee that not to exceed $25 for searching and handling recorded health care information would be injurious information.We may withhold your records until the fees are paid.The exceptions to this policy are contained in the attached Notice Form. If we refuse your request for access to your healthrecords, you have a right of review (except for information provided in confidence by another individual other than another health care provider), which we will discuss with you upon request. Patient Rights HIPAA provides you with several new or expanded rights with regard to clinical records your Clinical Records and disclosures of protected health information. .These rights include requesting that I we amend your record; requesting restrictions on what information from your clinical record Clinical Records is discloseddisclosed to others; requesting an accounting of disclosuresmost disclosures of protected health information that you have neither consented to nor authorized; determining where the location to which protected information disclosures are sent; having any complaints you make about my our policies and procedures recorded in your records; and the right to a paper copy of this agreementAgreement, my the attached Notice form, and our privacy policies and procedures, and the attached HIPAA notice form.We are happy to discuss any of these rights with you. Minors & Parents Parents of clients 16 Patients under 18 years of age who are not emancipated from their parents should be aware that the law may be allowed by law allow parents to examine their child’s treatment records. While Because privacy in psychotherapy is very importantoften crucial to successful progress, particularly with teenager, parental involvement is also essential to successful treatment. Thereforeteenagers, it is my sometimes our policy when treating 16- to 18-year-olds to request an agreement from parents that they agree consent to my sharing occasional give up their access to their child’s records. If they agree, during treatment, we will provide them only with general information about the progress of treatment with the child’s treatment, and his/her parentsattendance at scheduled sessions.We will also provide parents with a summary of their child’s treatment when it is complete. Unless I Any other communication will require the child’s Authorization, unless we feel discussing disclosure prior to parental notification is not realistic, such as when that the child is in danger or is a danger to someone else, I in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the childclient, if possible, and do our best to handle any objections he or she may have. Billing and Payments You are expected to pay for each session at the time it is held. If you have insurance, you must pay for your session in advance, with the exception of Blue Cross Blue Shield, Tricare, Medicare and Medicaid, in which case you are expected to pay you copayment and any deductible at the time of each session. Monthly bills are sent to notify you of any outstanding charges. In circumstances of financial hardship, we will be willing to negotiate a payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment.This may involve a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a client’s treatment is his or her name, the nature of services provided, and the amount due. Insurance Reimbursement In order for us to set realistic treatment goals and priorities, it is important to evaluate what I think resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment.We will fill out and submit insurance claims and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers.We advise you to carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, many clients feel that they need more services after insurance benefits end. Your contract with your health insurance company requires that we provide it with information relevant to the services that we provide to you.We are required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, we will inform you and make every effort to release only the minimum information about you that is necessary for the purpose requested.This information will become part of the insurance company files and will probably be stored in a computer.Though all insurance companies licensed in Montana claim to keep such information confidential and protect its privacy, we have no control over what they do with it once it is in their best interest hands.We will provide you with a copy of any report we submit, if you request it. By signing this Agreement, you agree that we can provide requested information to your insurance carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the parents benefits that are available and preferably both what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the child and I will talk with right to pay for our services yourself to avoid the parents together.problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Printed Name Signature Date
Appears in 1 contract
Samples: Psychotherapy Services Agreement
Limits of Confidentiality. The law protects It is important that you understand the privacy laws of the State of Texas and all communications between a patient and a psychologistexceptions to confidentiality. In most certain situations, I can only release information about your treatment to others if you sign a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland law. However, in the following situations, no authorization is required: I may occasionally find it helpful to consult other health and mental health professionals are required by law to reveal information obtained during therapy to other persons or agencies without your permission. This includes the following: • Confidentiality does not apply to cases of suspected abuse/neglect of children under the age of 18 by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare. • Confidentiality does not apply to cases of suspected abuse/neglect of a vulnerable adult (disabled, elderly, etc.) • Confidentiality does not apply to cases of potential harm to self, to others, or to society. • A mental health professional may disclose confidential information in proceedings brought by a client against a professional. • Confidentiality may not apply in cases involving legal proceedings affecting the parent-child relationship, including subpoenas to testify in court, or court-ordered to disclose confidential information • Confidentiality may not apply to cases involving the minor child. In such cases, the counselor may advise a parent, managing conservator, or guardian of a minor, with or without the minor’s consent, of the treatment needed by or given to the minor. For additional information about a case. During a consultationprivacy, I make every effort to avoid revealing confidentiality, and the identity limitations of my patient. The other professionals are also legally bound to keep the information confidentialconfidentiality, please review Healing Minds Behavioral Health, PLLC’s Notice of Privacy Practices. If you don’t objector your child has any questions regarding confidentiality, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report please discuss them with the appropriate government agency, usually the local office of the Department of Social Services. Once such a report is filed, I may be required to provide additional information. If I know Licensed Professional Counselor so that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns can be addressed. Consent Regarding Electronic Medical Records: Healing Minds Behavioral Health currently uses Simple Practice software to maintain electronic health records for all clinical services provided. For clients with existing records that are disclosed and provided to Healing Minds Behavioral Health, they will be scanned and stored electronically as well. Passwords to access client records are not shared with anyone outside of the organization for any reason. Court Disclaimer: Healing Minds Behavioral Health counselors will not have any therapeutic involvement in any ongoing custody cases or cases that may lead to civil court hearings for the purposes of determination of custody. Texas Family Code 104.008 prohibits our testimony and does not allow us to offer an expert opinion or recommendation to the conservatorship of or possession of or access to a child at issue in a suit unless we have conducted a child custody evaluation relating to the child. We are NOT custody evaluators, nor can we assume that dual role if you may have, now have chosen us to be the therapist for you or your child. We will be happy to provide a referral to a forensic counselor and we will remain out of the court room. Subpoenas: Please refer to the fee schedules found below to see all applicable fees in the futureevent that a subpoena is issued. Please note that your signature on this document is considered to be consent by you to pay all fees billed to you that are related to court costs (i.e. travel, copying of records, clinical summaries, securing of attorney/legal consultation, etc.) regardless of whether or not you initiated the court proceedings. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying subpoena fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger addition to someone else, I will discuss with the child, what I think is counseling service fees outlined in their best interest to discuss with the parents our document titled “New Client Intake and preferably both the child and I will talk with the parents togetherFinancial Agreement”.
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Samples: uploads-ssl.webflow.com
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistmental health professional. In most situations, I we can only release information about your treatment to others if you sign a consent written authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPPA. HoweverThere are situations that require only that you provide written, in the following situations, no authorization is requiredadvance consent. Your signature on this Agreement provides consent for those activities as follows: I • We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my our patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel that it is important to our work together. I We will note all consultations in your Clinical Record clinical record (which is called “PHI” in my our Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures There are some situations where we are permitted or required by health insurers to disclose information without either your consent or to collect overdue fees are discussed elsewhere in this Agreement. Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologistclinician-patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, 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 us to disclose information. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a patient files a complaint or lawsuit against mehis/her clinician, I that clinicians may disclose relevant information regarding that patient in order to defend myselfthemselves. There are some situations in which I am we are legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my our practice: . • If I we have reason cause to believe that a childchild under 18 has been or may be abused or neglected (including physical injury, adolescentsubstantial threat of harm, mental or emotional injury, or vulnerable adult has been subjected to abuse any kind of sexual contact or neglectconduct), or that a vulnerable adult has been subjected to self-neglectchild is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I file we make a report with to the appropriate government governmental agency, usually the local office of the Department of Social Family Protective Services. Once such a report is filed, I we may be required to provide additional information. • If I know we determine that there is a patient has a propensity for violence and probability that the patient indicates that he/she has the intention to will inflict imminent physical injury on another, or that the patient will inflict imminent physical, mental or emotional harm upon a specified victim(s)himself/herself, I or others, we may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated action by disclosing information to eliminate the possibility that the patient will carry out the threat, seeking medical or law enforcement personnel or by securing hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. However, in cases that involve child abuse, Section 611 of the Texas Health and Safety laws allows for clinicians to refuse to disclose information to a parent who may pose substantial harm to a child either physically or emotionally. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we you discuss any questions or concerns that you may have, have now or in the futurefuture with your psychologist/therapist. The laws governing confidentiality can be quite complex, and I am the clinicians at MOCE are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.PROFESSIONAL RECORDS
Appears in 1 contract
Samples: ministryofcounseling.com
Limits of Confidentiality. The law protects the privacy of all communications between a patient client and a psychologisttherapist. In most situations, I can only release information about your treatment to others only if you sign a consent written authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. HoweverThere are other situations involving uses and disclosures for treatment, in payment and healthcare operations that require only that you provide written, advanced consent. The Notice of Privacy Practices also describes these uses and disclosures for treatment, payment and healthcare operations. You have the following situationsright to and should review the Notice of Privacy Practices before signing this Agreement. Your signature on this Agreement provides consent for uses and disclosures for treatment, no authorization is requiredpayment and healthcare operations such as the following: • I may occasionally find it helpful to consult with other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patientclient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health InformationPractices). Disclosures required by I may also need to consult with another health insurers care provider, such as your family physician or another therapist to coordinate or manage your health care and other services related to your health care. • If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to collect overdue fees contact family members or others who can help provide protection. There are discussed elsewhere in this Agreement. some situations where I am permitted or required to disclose information without either your consent or authorization: • If you are involved in a court or administrative proceeding and a request is made for information concerning your diagnosis and treatmentmy professional services, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files you file a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself• If you file a worker’s compensation claim. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patientclient’s treatment. These situations are unusual in my practice: • If I have reason to believe that a child, adolescent, or vulnerable adult child has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitationabused, the law requires that I file a report with the appropriate government governmental agency, usually the local office of the Department of Social Family and Child Services. Once such a the report is filed, I may be required to provide additional information. • If I know have reasonable cause to believe that a patient disabled adult or elder person has been neglected or exploited,. • If I determine that a propensity for client presents a serious danger of violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s)another or himself, I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate notifying the possibility that potential victim, and/or contacting the patient will carry out the threatpolice, and/or seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patientclient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws PROFESSIONAL RECORDS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and standards disclosures of the profession require that I keep Protected Health Information (PHI) about each client ). These rights are described more fully in their clinical recordthe Notice of Privacy Practices. In some circumstancesPursuant to HIPAA, I may keep some information in two sets of professional recordsProtected Health Information. One set is your clinical record. It Your Clinical Record includes information about your reasons for seeking therapy and how these and related issues impact on therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, progress towards the those goals, your medical treatment and social history, treatment history, past treatment records that I receive from other providers, reports of any professional consultations, billing records, and any reports that have been sent to insurance carriers anyone. Except in unusual circumstances that involve danger to yourself or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would Clinical Record, if requested in writing. Because these are professional records, they can be injurious misinterpreted and/or upsetting to your healthuntrained readers. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of For this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone elsereason, I recommend we review them together, or have them forwarded to another mental health professional so you can discuss the contents. Normal hourly charges and/or copying charges will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents togetherapply.
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Samples: Counseling Services Agreement
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a consent written Authorization form that meets certain legal requirements imposed by HIPAA state law and/or Maryland lawHIPAA. HoweverWith your signature on a proper Authorization form, I may disclose information in the following situations, no authorization is required: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which Record. You should be aware that I practice with other mental health professionals in some cases and that I sometimes employ administrative staff. You will be notified if that is called “PHI” in my Notice the case. In most cases, I need to share your protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of Psychologist’s Policies the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and Practices have agreed not to Protect release any information outside of the Privacy practice without the permission of Your Health Information)a professional staff member. Disclosures There are some situations where I am permitted or required by health insurers to disclose information without either your consent or to collect overdue fees are discussed elsewhere in this Agreement. If Authorization: •If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege 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 •If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If •If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. There •If a patient files a worker’s compensation claim, he/she automatically authorizes me to release any information relevant to that claim. •Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. •There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that . •If there is a child, adolescent, or vulnerable adult has been subjected to child abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitationinvestigation, the law requires that I file a report with turn over my patient’s relevant records to the appropriate government governmental agency, usually the local office of the Department of Social Human Services. Once such a report is filed, I may be required to provide additional information. If •If there is an elder abuse or domestic violence investigation, the law requires that I know turn over my patient’s relevant records to the appropriate governmental agency, usually the local office of the Department of Human Services. Once such a report is filed, I may be required to provide additional information. •If I believe that a patient has presents a propensity for violence clear and the patient indicates that he/she has the intention substantial risk of imminent, serious harm to inflict imminent physical injury upon a specified victim(s)another person, I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate notifying the possibility that potential victim, contacting the patient will carry out the threatpolice, or seeking hospitalization of for the patient and/or informing the potential victim or the police about the threatpatient. If •If I believe that there is an imminent risk that a patient will inflict presents a clear and substantial risk of imminent, serious physical harm or death on to him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needsher self, I may be required obligated to take appropriate protective actionsseek hospitalization for him/her, including initiating hospitalizations and/or notifying or to contact family members or others who can protect help provide protection. •When fees for services are not paid in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the patientservices (e.g., diagnosis, treatment plan, case notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the client’s credit report may state the amount owed, time frame, and the name of the clinic. •Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, have now or in the future. The laws governing confidentiality can be quite complex, complex and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws HIPAA Notice Notice of Psychologists’ Policies and standards Practices to Protect the Privacy of the profession require that I keep Protected Your Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.Information
Appears in 1 contract
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a consent written authorization form that meets certain legal requirements imposed by HIPAA and/or Maryland lawHIPAA. However, in the following situations, no authorization is requiredSome exceptions are: If a patient seriously threatens to harm himself/herself or another person If I have cause to believe that a child under 18 (or person 65 and older) has been or may be abused or neglected If a court order or other legal proceedings or statute require disclose. I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object You should be aware that I employ administrative staff. In most cases, I will not tell you about need to share protected information with these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies individuals for both clinical and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentadministrative purposes, such information is protected by the psychologist-patient privilege lawas scheduling, billing and quality assurance. I canAll staff members have been given training about protecting your privacy and have agreed not provide to release any information outside of the practice without your written authorization, or the permission of a court orderprofessional staff member. 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 government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. There If a patient files a worker’s compensation claim, I must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought. If your report to me that you are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that victim of sexual abuse by a child, adolescent, mental health professional or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency, usually the local office member of the Department of Social Services. Once such a report is filed, I may be required to provide additional information. If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. If I believe that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members or others who can protect the patientclergy. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conservations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your clinical record. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.
Appears in 1 contract
Samples: austinpsych.com
