Common use of CONFIDENTIALITY AND FILES Clause in Contracts

CONFIDENTIALITY AND FILES. The laws governing confidentiality can be quite complex. The attached Notice explains some specific Patient Rights that you have under the HIPAA law. A Clinical Record on your case will be maintained on file; which is the property of InnerVision Therapy. You may examine and/or receive a copy of your file if you request it in writing and the request is signed by you and dated not more than 60 days from the date it is submitted. There may be a charge for writing reports or for copying materials. In most situations, InnerVision Therapy can release information about your treatment to others only if you sign a written authorization form for each release. However, in other situations, InnerVision Therapy needs only written, advance consent to release information. Your signature on this agreement is written, advance consent for the following releases of information:  Your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During consultations, your therapist makes every effort to avoid revealing the identity of patients. The other professionals are also legally bound to keep the information confidential. The therapist will note all consultations in your Clinical Record.  Your therapist may find it helpful to receive or exchange information with your primary care physician or other health and mental health professionals who are currently treating you. Your signature on this Agreement is written, advance consent for release of information to these professionals. A record of any disclosures will be kept in your Clinical Record. Check here if you do NOT wish InnerVision Therapy to release any information to other mental health and health professionals who are currently treating you. There are some situations where InnerVision Therapy is permitted or required to use or disclose information without either your consent or authorization:  If a client is clearly likely to seriously harm him/herself, InnerVision Therapy may be required to take action to prevent self-destruction.  If there is a clear risk that a client plans to seriously harm another person, InnerVision Therapy has a duty to warn the potential victim or disclose the risk to appropriate public authorities.  If a therapist suspects that abuse of a child or senior citizen may have taken place, the therapist is required to report the suspected abuse to the Department of Social and Health Services.  If the client is a minor, both parents have access to the minor client’s complete Clinical Record; including Psychotherapy Notes, unless there is a court order prohibiting one of the parents from access.  If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by the counselor-client privilege law. InnerVision Therapy cannot provide any information without your (or your personal or legal representative’s) written authorization. However, if a court orders InnerVision to disclose information, we are required to provide it. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order InnerVision Therapy to disclose information.  If a client files a complaint or lawsuit against InnerVision Therapy or any of its staff, InnerVision Therapy may disclose relevant information regarding that patient in order to defend itself.  If a client files a worker’s compensation claim, the client must sign an authorization; so that InnerVision Therapy may release the information, records or reports relevant to the claim.  InnerVision Therapy may present disguised case material in seminars, classes or scientific writings. In this situation, all identifying information and PHI is removed to maintain client confidentiality and anonymity. 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 OF PRIVACY PRACTICES DESCRIBED ABOVE.

CONFIDENTIALITY AND FILES. The laws governing confidentiality can be quite complex. The attached Notice explains some specific Patient Rights that you have under the HIPAA law. A We will maintain a Clinical Record file on your case will be maintained on file; case, which is the property of InnerVision TherapyInsight Integration. You may examine and/or receive a copy of your file if you request it in writing and the request is signed by you and dated not more than 60 days from the date it is submitted. There may be a charge for writing reports or for copying materials. In most situations, InnerVision Therapy Insight Integration can release information about your treatment to others only if you sign a written authorization form for each release. However, in other situations, InnerVision Therapy needs only written, advance consent I am a mandated reporter and there are a few situations where I am required to release informationdisclose information to authorities. Your signature on this agreement is written, advance consent for the following releases of information:  • Your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During consultations, your therapist makes every effort to avoid revealing the identity of patients. The other professionals are also legally bound to keep the information confidential. The therapist will note all consultations in your Clinical Record.  • Your therapist may find it helpful to receive or exchange information with your primary care physician or other health and mental health professionals who are currently treating you. Your signature on this Agreement is written, advance consent for me to release of information to these professionals. A record of any disclosures will be kept in your Clinical Record. Check here if you do NOT wish InnerVision Therapy us to release any information to other mental health and health professionals who are currently treating you. There are some situations where InnerVision Therapy Insight Integration is permitted or required to use or disclose information without either I your consent or authorization:  • If a client is clearly likely to seriously harm him/herself, InnerVision Therapy we may be required to take action to prevent self-destructionself-­‐destruction.  • If there is a clear risk that a client plans to seriously harm another person, InnerVision Therapy has we may have a duty to warn the potential victim victim; or disclose the risk to appropriate public authorities.  • If a therapist suspects that abuse of a child or senior citizen may have taken place, the therapist is required to report the suspected abuse to the Department of Social and Health Services.  • If the client is a minorminor younger that age 13, both parents have access to the minor client’s complete Clinical Record; , including Psychotherapy Notes, unless there is a court order prohibiting one of the parents from access.  • If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by the counselor-client counselor-­‐client privilege law. InnerVision Therapy Insight Integration cannot provide any information without your (or your personal or legal representative’s) written authorization. However, if a court orders InnerVision or subpoenas Insight Integration Counseling and Art Therapy, LLC to disclose information, we are required by law to provide it. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order InnerVision Therapy us to disclose information.  • If a client files a complaint or lawsuit against InnerVision Therapy Insight Integration or any of its staff, InnerVision Therapy Insight Integration may disclose relevant information regarding that patient in order to defend itself.  • If a client files a worker’s compensation claim, the client must sign an authorization; authorization so that InnerVision Therapy Insight Integration may release the information, records or reports relevant to the claim.  InnerVision Therapy • Insight Integration may present disguised case material in seminars, classes classes, or scientific writings. In this situation, all identifying information and PHI Protected Health Information is removed to maintain removed, and client confidentiality and anonymityanonymity is maintained. 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 OF PRIVACY PRACTICES DESCRIBED ABOVE.

CONFIDENTIALITY AND FILES. The laws governing confidentiality can be quite complex. The attached Notice explains some specific Patient Rights that you have under the HIPAA law. A We will maintain a Clinical Record file on your case will be maintained on file; case, which is the property of InnerVision Therapy. You may examine and/or receive a copy Concepts of your file if you request it in writing and the request is signed by you and dated not more than 60 days from the date it is submitted. There may be a charge for writing reports or for copying materials. Truth, Inc. In most situations, InnerVision Therapy we can release information about your treatment to others only if you sign a written authorization form for each release. However, licensed professionals are mandated reporters and there are a few situations where we are required to disclose information to authorities. These situations are listed below:  If a client is clearly likely to seriously harm him/herself, we may be required to take action to prevent self- destruction.  If there is a clear risk that a client plans to seriously harm another person, we may have a duty to warn the potential victim; or disclose the risk to appropriate public authorities.  If a therapist suspects that abuse, neglect, or exploitation of a child or incapacitated adult may have taken place, the therapist is required to report the suspected abuse to the Department of Social and Health Services.  If a therapist believes someone if engaging or intends to engage in other situationsbehavior which will expose another person to a potentially life-threatening communicable disease  If a therapist believes someone’s mental condition leaves the person gravely disabled.  If you are involved in a court proceeding and a request is made for information concerning your evaluation, InnerVision Therapy needs only writtendiagnosis or treatment, advance consent such information is protected by the counselor-client privilege law. Concepts of Truth, Inc. cannot provide any information without your (or your personal or legal representative’s) written authorization. However, if a court orders or subpoenas Concepts of Truth, Inc. to release disclose information, we are required by law to provide it. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.  If a client files a complaint or lawsuit against Concepts of Truth, Inc. or any of its staff, Concepts of Truth, Inc. may disclose relevant information regarding that patient in order to defend itself.  If a client files a worker’s compensation claim, the client must sign an authorization so that Concepts of Truth, Inc. may release the information, records or reports relevant to the claim.  Concepts of Truth, Inc. may present disguised case material in seminars, classes, or scientific writings. In this situation, all identifying information and Protected Health Information is removed, and client confidentiality and anonymity is maintained. Client Services Agreement Pg. 3 Your signature on this agreement is written, advance consent for the following releases of information:  Your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During consultations, your therapist makes every effort to avoid revealing the identity of patients. The other professionals are also legally bound to keep the information confidential. The therapist will note all consultations in your Clinical Record. Also, Xxxxxx Xxxx, MSE, LPC is a supervisor for LAC’s and pre/post master’s level interns from nearby universities. All interns or therapists will state their level of training or licensure during the initial intake session.  Your therapist may find it helpful to receive or exchange information with your primary care physician or other health and mental health professionals who are currently treating you. Your signature on this Agreement is written, advance consent for me to release of information to these professionals. A record of any disclosures will be kept in your Clinical Record. Check here if you do NOT wish InnerVision Therapy us to release any information to other mental health and health professionals who are currently treating you. There are some situations where InnerVision Therapy is permitted or required to use or disclose information without either your consent or authorization:  If a client is clearly likely to seriously harm him/herself, InnerVision Therapy may be required to take action to prevent self-destruction.  If there is a clear risk that a client plans to seriously harm another person, InnerVision Therapy has a duty to warn the potential victim or disclose the risk to appropriate public authorities.  If a therapist suspects that abuse of a child or senior citizen may have taken place, the therapist is required to report the suspected abuse to the Department of Social and Health Services.  If the client is a minor, both parents have access to the minor client’s complete Clinical Record; including Psychotherapy Notes, unless there is a court order prohibiting one of the parents from access.  If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by the counselor-client privilege law. InnerVision Therapy cannot provide any information without your (or your personal or legal representative’s) written authorization. However, if a court orders InnerVision to disclose information, we are required to provide it. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order InnerVision Therapy to disclose information.  If a client files a complaint or lawsuit against InnerVision Therapy or any of its staff, InnerVision Therapy may disclose relevant information regarding that patient in order to defend itself.  If a client files a worker’s compensation claim, the client must sign an authorization; so that InnerVision Therapy may release the information, records or reports relevant to the claim.  InnerVision Therapy may present disguised case material in seminars, classes or scientific writings. In this situation, all identifying information and PHI is removed to maintain client confidentiality and anonymity. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREEMENT, AGREE TO ITS TERMS, TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA HIPPA PRIVACY NOTICE OF PRIVACY PRACTICES DESCRIBED ABOVE.. Client or responsible party Date □ I hereby consent for Xxxxxx Lace, MSE, LPC License #POO11032 □ I hereby consent for Xxxx Xxxxxxx Xxxxx, LAC License #A1307071 to provide treatment to me in accordance with the Code of Ethics and Standard of Practice as adopted by the American Counseling Association and the Arkansas Counselor’s Association. The primary responsibility of counselors is to respect the dignity and to promote the welfare of clients. It is the responsibility of the client to work jointly with the counselor in devising integrated, individual counseling plans that offer reasonable promise of success and are consistent with abilities and circumstances of clients. Counselors and clients regularly review counseling plans to ensure their continued viability and effectiveness, respecting clients’ freedom of choice. □ I hereby consent for treatment using Technology-Assisted Counseling in addition to Face to Face. I have read, understood, and signed the additional informed consent for Technology-Assisted Counseling. □ I understand counseling sessions may be videoed for supervision/consulting purposes and will be used only to facilitate treatment. Signature of Client/Person Authorized to act in behalf Date Fees for Counseling, Financial Agreement & Assignment of Benefits I understand that the counseling services I will receive will be contracted through Concepts of Truth, Inc. I understand that I am personally responsible for the cost of services that I will receive from Concepts of Truth, Inc. and that I may use a third party source to satisfy my bill. However, fees for services are supplemented by public support and will be determined by a sliding scale. The standard fee for a 50 minute counseling session is $125 per session. A session is generally 50 minutes in length with 10 minutes for record keeping. Longer sessions are charged as a prorated fee. Indirect services such as treatment planning, case management or other forms not directly performed with client present additionally may be charged to client. In the event of any court subpoena, fees will be charged for counseling services as appropriate. Some proof of gross annual income may be required to be placed on the sliding fee scale for face to face sessions only. This may be an income tax return, a paycheck stub or some other proof of income. There is no sliding scale for distance or technology-assisted counseling. Concepts of Truth, Inc. Session Fee Sliding Scale Gross Annual income Fee $ 0 - 25,000 $ 75.00 25,001 - 32,500 85.00 32,500 - 37,500 95.00 37,501 - 50,000 105.00 50,000 - 60,000 115.00 60,000+ 125.00 Fee Agreement Fee for one session

CONFIDENTIALITY AND FILES. The laws governing confidentiality can be quite complex. The attached Notice explains some specific Patient Rights that you have under the HIPAA law. A I will maintain a Clinical Record file on your case will be maintained on file; child/family’s case, which is the property of InnerVision TherapyXx. Xxxxxxxxxx. You may examine and/or receive a copy of your file if you request it in writing and the request is signed by you and dated not more than 60 days from the date it is submitted. There may be a charge for writing reports or for copying materials. In most situations, InnerVision Therapy Xx. Xxxxxxxxxx can release information about your treatment to others only if you sign a written authorization form for each release. However, in other situations, InnerVision Therapy needs only written, advance consent I am a mandated reporter and there are a few situations where I am required to release informationdisclose information to authorities. These situations are listed on page 3. Your signature on this agreement is written, advance consent for the following releases of information:  Your therapist ● I may occasionally find it helpful to consult other health and mental health professionals about a case. During consultations, your therapist makes I make every effort to avoid revealing the identity of patients. The other professionals are also legally bound to keep the information confidential. The therapist I will note all consultations in your Clinical Record.  o Check here if do NOT wish me to release any information to other mental health professionals who are currently treating you or your child. ● Your therapist may find it helpful to receive or exchange information with your primary care physician or other health and mental health professionals who are currently treating you. Your signature on this Agreement is written, advance consent for me to release of information to these professionals. A record of any disclosures will be kept in your Clinical Record. □ Check here if you do NOT wish InnerVision Therapy me to release any information to other mental health and health professionals who are currently treating youyou or your child. There are some situations where InnerVision Therapy Xx. Xxxxxxxxxx is permitted or required to use or disclose information without either your consent or authorization:  ● If a client is clearly likely to seriously harm him/herself, InnerVision Therapy he may be required to take action to prevent self-destruction.  ● If there is a clear risk that a client plans to seriously harm another person, InnerVision Therapy has he may have a duty to warn the potential victim victim; or disclose the risk to appropriate public authorities.  ● If a therapist he suspects that abuse of a child or senior citizen may have taken place, the therapist he is required to report the suspected abuse to the Department of Social and Health Child or Adult Protective Services.  ● If the client is a minorminor younger than age 13, both parents have access to the minor client’s complete Clinical Record; , including Psychotherapy Notes, unless there is a court order prohibiting one of the parents from access, or it is potentially harmful to the child for a parent to have access to the child’s Clinical Record.  ● If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by the counselor-client privilege law. InnerVision Therapy He cannot provide any information without your (or your personal or legal representative’s) written authorization. However, if a court orders InnerVision or subpoenas Xx. Xxxxxxxxxx to disclose information, we are he is required by law to provide it. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order InnerVision Therapy us to disclose information.  ● If a client files a complaint or lawsuit against InnerVision Therapy or any of its staffXx. Xxxxxxxxxx, InnerVision Therapy he may disclose relevant information regarding that patient in order to defend itselfhimself.  ● If a client files a worker’s compensation claim, the client must sign an authorization; authorization so that InnerVision Therapy Xx. Xxxxxxxxxx may release the information, records or reports relevant to the claim.  InnerVision Therapy ● Xx. Xxxxxxxxxx may present disguised case material in seminars, classes classes, or scientific writings. In this situation, all identifying information and PHI Protected Health Information is removed to maintain removed, and client confidentiality and anonymityanonymity is maintained. 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 OF PRIVACY PRACTICES DESCRIBED ABOVE.. Client or Responsible Party Date Continued on the next page Fees for Psychotherapy and Financial Agreement The standard fee for psychotherapy is $190-$225 per 50-minute session depending on location. However, quality healthcare should be available to everyone. In keeping with this belief, I will hold a few spots for a reduced fee. Once spots are filled, a reduced fee will not be available. Should your financial situation improve, I encourage you to remunerate the remainder of your fee. This will allow me to continue to serve everyone in the best possible way regardless of financial situations. Some proof of gross annual income may be required to be placed on the reduced fee scale. I also hold a few spots for single case agreements with insurance providers, if they are willing to negotiate a reasonable fee. An individual session is generally 50 minutes in length with 10 minutes for record keeping. Longer sessions are charged at a prorated fee. Often couple’s sessions, family sessions, and EMDR sessions run 80 minutes. Fee Agreement ● Fee for one session $