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 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. 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. HIPAA provides you with expanded rights 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. 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 3 contracts
Samples: Agreement & Informed Consent to Treatment, Agreement & Informed Consent to Treatment, Agreement & Informed Consent to Treatment
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 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. 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. HIPAA provides you with expanded rights 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. 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: Psychotherapist Patient Services Agreement, Psychotherapist Patient 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 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. 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. HIPAA provides you with expanded rights regarding 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. 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: Agreement & Informed Consent to Treatment, Informed Consent 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 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. 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. HIPAA provides you with several new or expanded rights regarding clinical records with regard to 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. 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 '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
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I your therapist 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 your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I your therapist will make every effort to avoid revealing the identity of my his/her patient. The other professionals are also legally bound to keep the information confidential. If you don’t n't object, I your therapist will not tell you about these consultations unless I feel he/she feels that it is important to our your work together. I Your therapist 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 It is also important to be aware of other potential limits to confidentiality that include the following: ● All records as well as notes on sessions and phone calls can be subject to court subpoena under certain extreme circumstances. Most records are stored in locked files but some are stored in secured electronic devices. ● Cell phones, portable phones, faxes, and e-mails are used on some occasions. ● All electronic communication compromises your confidentiality. ● If a patient seriously threatens to harm himself/herself, your therapist 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 your therapist is 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 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 files a complaint or lawsuit against meyour therapist, I he/she may disclose relevant information regarding that patient in order to defend myselfthemselves. ● If a patient files a worker's compensation claim, your therapist 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 your therapist has rendered, he/she may disclose relevant information in a suit seeking payment. There are some situations in which I am your therapist is legally obligated to take actions, which I believe he/she believes are necessary to attempt to protect others from harm harm, and I he/she may have to reveal some information about a patient’s 's treatment. These situations are unusual in my our practice: . ● If I have reason the therapist has 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 the therapist 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 the therapist may be required to provide additional information. ● If I know the therapist determines 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 the therapist 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 he/she will make every effort to fully discuss it with you before taking any action and and, I will limit my their disclosure to what is necessary. By signing this agreement, you authorize your therapist to contact any person/entity in a position to prevent harm to the patient or a third party if he/she determines 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 you and your therapist 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 your therapist is not an attorney. In situations where specific advice is required, formal legal advice consultation may be needed. The laws and standards of the our profession require that I your therapist keep Protected Health Information (PHI) about each client you 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 your reasons for seeking therapy and how these and related issues impact therapy, a description of the ways in which the problem impacts on your life, your the diagnosis, the goals that that you and your therapist set for treatment, progress towards the those goals, your medical treatment and social history, treatment history, any past treatment records I receive that your therapist receives 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 school (if applicable). 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 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 have them forwarded to another mental health professional so you can discuss the health care information would be injurious contents. In most circumstances, we charge a copying fee of $.50 per page (and for certain other expenses). If your therapist refuses your request for access to your healthrecords, you have a right of review, which he/she will discuss with you upon your request. HIPAA provides you with several new or expanded rights regarding clinical records with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I your therapist 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 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. Parents of clients 16 Patients 18 years of age who are not emancipated may be allowed by law to examine and older must consent for their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful own treatment. ThereforeIn order for therapists to communicate with parents, it is my policy when treating 16- he/she must have a signed release from the patient. If parents are paying for treatment of their adult son or daughter, the therapist can provide the patient with a receipt after each session that parents may use to 18-year-olds file an insurance company claim. In most cases in which a patient has given written permission to request that they agree to my sharing occasional general information about the progress of treatment speak with his/his or 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 therapist will discuss it 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 togetherpatient first.
Appears in 1 contract
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. 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. HIPAA provides you with expanded rights 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. 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 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. The laws 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. 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. 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. HIPAA provides 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 regarding 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. 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: Psychotherapist Patient 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 (or the treatment of a minor for whom you hold legal custody) 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 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 you Clinical Record (which Which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your your Health Information). Disclosures There are some situations where I am permitted or 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 disclose information without either 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 to defend myself. Authorization” There are some situations in which I am legally obligated to take actions, 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 suspect that a child has been abused or neglected, the law requires that I file a report with the Division for Children, Youth and Families. Once such a report is filed, I may be required to provide additional information. If I suspect or have good faith reason to believe that a child, adolescent, or vulnerable any incapacitated adult has been subjected to abuse or abuse, neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, or is living in a hazardous environment, the law requires that I file a report with the appropriate government governmental agency, usually the local office of the Department of Social Health and Human Services. Once such a report is filed, I may be required to provide additional information. If I know that a patient has client communicated a propensity for serious threat of physical violence and the patient indicates that he/she has the intention against a clearly identified or reasonably identifiable victim or victims, or a serious threat of substantial damage to inflict imminent physical injury upon a specified victim(s)real property, 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 notifying the potential victim or victim, contacting 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/herselfpolice, or that immediate disclosure is required to provide seeking involuntary 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 will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. There are some circumstances which do not create legal exceptions to your confidentiality but may limit it for practical reasons. These include: The use of various electronic methods of communication, including but not limited to voicemail, email, fax, and cellular telephones, may compromise your confidentiality. There are inherent risks in using electronic equipment and transmissions. I take all reasonable precautions to protect your privacy but cannot control what happens to information once it has been transmitted. In particular you should treat any email exchanged between us like a postcard, with the same level of privacy. It is important to note that I do not monitor my email on a daily basis. Thus, do not share/send any information via email in which you mention personal information or state that there is a crisis. Please attempt to contact me via phone and should you not be able to await my return call, contact your nearest emergency room and ask for the mental health counselor on call in that hospital. I generally use email only for rescheduling appointments and will limit any responses to your email to ensure your privacy. Should couples therapy be warranted and you or your partner have any individual sessions as part of the treatment, what you say in those individual session will be considered part of the couples therapy, and can and probably will be discussed in our joint session. Do not tell me anything you wish kept secret from your partner. I will remind you of this policy before beginning each individual session. You may request anyone you wish to attend a therapy session with you; however, any one else attending your session may not be constrained to maintain the privacy of your treatment. While this a written summary of the exceptions to of 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 on 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. The laws and standards of the profession require that 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 way 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, Individualized Education Plans from schools, 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 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 to client, they can include the contents content 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 recordyou Clinical Record. These psychotherapy notes Psychotherapy Notes are kept separate from your clinical recordyou Clinical Record. While insurance companies can request and receive a copy of your clinical recordyou Clinical Record, they cannot receive a copy of your psychotherapy notes you Psychotherapy Notes without your signed, written authorizationAuthorization. Insurance companies cannot require your authorization you to Authorize as a condition of coverage nor penalize you in any way for your you refusal. You may examine and/or receive a copy of both sets of records, if you request in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health provider so you can discuss the contents. I am sometimes willing to conduct this review without charge. In most circumstances, I am allowed to charge a copying fee of $15.00 for the first 30 pages or 50 cents per page, whichever is greater. The exceptions to this policy are contained in the Notice of my policies and practices, which I have also given you today. I maintain your psychotherapy notes unless records in a secure location in my office, which is located at the 0 Xxxx Xxxx Xxxxxx #000, Xxxxxxx Xxxxxxxx Block, Lebanon NH 03766. I determine that knowledge also have a computer disk which is password protected. I will maintain your clinical record and business records for a minimum of 7 years after the last activity on your account. Should a client be a minor, I will maintain the record for minimum of 7 years after the minor reaches the age of 18. A summary of your record will be kept for a minimum of 12 years prior to the disposal, in accordance with the New Hampshire laws and current American Psychological Association guidelines. I have made provisions for a professional colleague to handle the disposition of the health care information would be injurious records I keep, in the event of my inability to your healthcontinue to practice or my death. HIPAA provides you with several new or expanded rights regarding clinical records with regard to 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 Record is discloseddisclosed to others; requesting an accounting of disclosuresmost disclosures of protected health information that you have neither consented to nor 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. You have the right to ask questions or raise concerns about anything that happens in therapy. I am always willing to discuss how and why I have decided to do what I am doing, and to look at alternatives that might work better. If you feel that I am in need of getting better information about a topic of concern to you, please let me know. I am always open to your suggestions and concerns. You can ask me about my training for working with your concerns, and can request that I refer you to someone if you decide I am not the right therapist for you. There is a brief description of my background and training available upon your request. I adhere to the most recent Ethical Principles of Psychologists and Code of Conduct of the American Psychological Association. I can provide you with a copy or there is a copy of this Code on line at http//xxx.xxx.xxx/xxxxxx, or by calling the office of the New Hampshire Psychological Association (225-9925) and asking for a copy. I do not have social or sexual relationships with clients or former clients because that would be unethical and illegal, and it would abuse the therapeutic relationship. You are; of course, free to leave therapy at any time. You have the right to decide when therapy will end with some exceptions. If we have contracted for a specific short-term piece of work, we will normally finish therapy at the end of that contract. If I judge that I am not able to help you, either because of the kind of problem you have or because my training and skills are not sufficient, my ethics require that I inform you of this fact and refer you to another therapist who can meet you needs. In any case, I will provide you with names of other possible therapists if you so desire. 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 (NH Medicaid only) 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 payment installment plan or fee discount. It is important to note that I am not on any insurance provider panels, with the exception of NH Medicaid. This Agreement signifies that you will pay out of pocket and submit bills to your insurance company, should you decide to attempt to be partially reimbursed for therapy expenses. I am happy to fill out any form you may need to give to your insurer in an attempt to be reimbursed, but I will not be responsible for sending any documentation to your insurance provider. You must arrange for any preauthorization for an out-of-network provider service from you insurer. I am not willing to have clients run a bill with me. If you find that you are having a hard time paying for therapy, please discuss it with me. I am willing to discuss setting up a payment plan or reduced fee. I do keep a few slots in my practice reserved for reduced-fee clients, and if one of those is open, I might make it available. Other options include meeting less frequently or making an agreement about paying installments. If your financial circumstances improve, please let me know so that we can readjust our agreement. Payment made at the point of service delivery will result in a negotiated reduction in our agreed upon fee, which will be documented and signed. I will not accept barter for therapy. I am a participating provider for NH Medicaid and accept assignment from them. I am not a provider for other insurers and will not accept assignment from them, making you responsible for paying the difference between what the insurance company may reimburse you for a pre-authorized out-of-network provider session and my standard fee. Should your treatment be covered by a school district, a copy of the treatment agreement is needed for your Clinical Record and I will bill the school district directly each month. Billing a school district requires that I send a monthly record of the services rendered. I will not share any information other than date/duration and type of service rendered. An Authorization will be necessary to allow for billing to the school district. 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 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 client’s treatment is his/her name, the nature of services provided, and the attached HIPAA notice formamount due. 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 If such legal action is very important, particularly with teenager, parental involvement is also essential to successful treatment. Thereforenecessary, it is my policy when treating 16- to 18-year-olds to request costs will be included in the claim. I am not a participating provider for any insurance company other than NH Medicaid. In some cases this means that they agree to my sharing occasional general information the insurance company will not approve or pay for your therapy with me. You should carefully read the section in you insurance coverage booklet that describes mental health services. If you have questions about the progress of treatment with his/her parentscoverage, call you 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 upon my 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, I am willing to call the company on your behalf. Some managed care plans will not partially reimburse your out-of-pocket expenses for my services. In these instances, you have the option to consider utilizing in-network providers. You should also be aware that your contract with you health insurance company requires you to provide them with information relevant to the services I provide you. I am happy to provide a clinical diagnosis and any other clinical information such as treatment plans or summaries, or copies of my entire Clinical Record, should you decide to request partial reimbursement from your insurer for my services. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with the child, what I think information you send them once it is in their best interest hands. I will provide you with any necessary documentation and it will be your responsibility to discuss request any potential reimbursements from your insurer. I will not mail, fax, or email any information to you insurer (with the parents and preferably both exception of NH Medicaid). Once we have all of the child and I information about self-payment for services, NH Medicaid coverage, or a signed treatment agreement from a school district for payment of services, we will talk discuss what we can expect to accomplish with the parents togetherbenefits that are available and what will happen if they run out before you feel ready to end your sessions.
Appears in 1 contract
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. 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. HIPAA provides you with expanded rights 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. 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: Client Services Agreement
Limits of Confidentiality. The law protects the privacy of all communications between If we believe that a patient and a psychologist. In most situationsclient presents an imminent danger to his/her health or safety, I can only release information about your treatment we may be obligated to others if you sign a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland law. Howeverseek hospitalization for him/her, 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 contact family members or others who can help provide protection. There are discussed elsewhere in this Agreement. 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 psychologistcounselor-patient client privilege law. I We cannot provide any information without your written authorization, or a court order. If you y xxxx ou are involved in or contemplating litigation, you should consult with conwith 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 client files a complaint or lawsuit against meRHEMA Counseling & Support Services, I PC or an individual provider within the agency, we may disclose relevant information regarding that patient client. • If a client files a worker’s compensation claim, and our services are being compensated through workers compensation benefits, we must, upon appropriate request, provide a copy of the client’s record to defend myselfthe client’s employer or the North Carolina Industrial Commission. 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 Though these situations are unusual in my our practice, we would like to make you aware of them: • If I we have reason cause to suspect that a child under 18 is abused or neglected, or if we have reasonable cause to believe that a child, adolescent, or vulnerable disabled adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitationis in need of protective services, the law requires that I we file a report with the appropriate government agency, usually the local office of the County Department of Social Services. Once such a report is filed, I we may be required to provide additional information. • If I know we believe that a patient has a propensity for violence client presents an imminent danger to the health and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s)safety of another, I we 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 disclose information in order to take appropriate protective actions, including initiating hospitalizations hospitalization, warning the potential victim, if identifiable, and/or notifying family members or others who can protect calling the patientpolice. If such a situation arises, I we 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 we are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed. 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. HIPAA provides you with several new or expanded rights regarding clinical records with regard to 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 agreement, my Agreement and our privacy policies and procedures, and the attached HIPAA notice form. Parents of clients 16 years of age who We 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 happy to discuss any of these rights with you. In addition, you will receive a copy of these rights in RHEMA Counseling & Support Services, PC’s Notice of Privacy Practices. We reserve the parents right to revise the terms of this Notice and preferably both make the child and I new Notice effective for all medical information that we maintain. A copy of these revisions will talk with the parents togetherbe posted online at xxx.xxxxxxxx.xxx. You may also obtain a copy from our office located at 0000 Xxxxxxxx Xxxxx, Xxxxxx, XX 27713 or you may request a copy by calling (919) 000- 0000.
Appears in 1 contract
Samples: Counselor Client Services Agreement
Limits of Confidentiality. The law protects In general, the privacy of all communications between a patient client and a psychologist. In most situationstherapist or psychologist is protected by law, I and we can only release information about your treatment our work to others if with your written permission. But, there are a few exceptions: In most legal proceedings, you sign have the right to prevent us from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland lawjudge may order our testimony. However, in the following situations, no authorization such an order is required: I may occasionally find it helpful unlikely. We would advise you never to consult other health and mental health professionals about a case. During a consultation, I make every effort agree to avoid revealing the identity any release 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 first discussing it 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 to defend myselfus. 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 others from harm and I may harm, even if we have to reveal some information about a patientclient’s treatment. These situations are unusual in my practice: If I have reason to For example, if we believe that a child, adolescentelderly person or disabled person is being abused, 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 we must file a report with the appropriate government state 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 we believe that a patient has a propensity for violence and the patient indicates that he/she has the intention client is threatening bodily harm to inflict imminent physical injury upon a specified victim(s)another, 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 the patient and/or informing the potential victim or the police about the threatfor our clients. If I believe that there is an imminent risk that a patient will inflict serious physical client threatens harm or death on himto herself/herselfhimself, 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 a higher level of care including hospitalization, including initiating hospitalizations and/or notifying to contact family members or others who can protect the patientmay help provide protection. If such a similar situation arisesoccurs in the course of our work together, I we will attempt to fully discuss it with you before taking any action. The prior situations have rarely occurred in our practice. If a similar situation occurs, we will make every effort to fully discuss it with you before taking any action and I action. We may occasionally find it helpful to consult with other professionals about a client in order to provide best care. During a consultation, we make every effort to completely disguise the identity of each client. Consultants are also legally bound to keep information confidential. If you don’t object, we typically will limit my disclosure not tell you about these consultations unless we believe it is important to what is necessaryour work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problemsexceptions to confidentiality, it is important that we to discuss any questions or concerns that you may havehave as we go along. We will be more than happy to discuss these issues with you. Please note, now or in however, that we are not an attorneys, and formal legal advice is sometimes warranted because the future. The laws governing confidentiality can be are quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. 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. HIPAA provides you with expanded rights 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. 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. Date
Appears in 1 contract
Samples: Intake Packet
Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologisttherapist. In most situations, I your therapist 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 Iowa law. However, in the following certain specific situations, no authorization is required, such as: I Your therapist may occasionally find it helpful to consult with other health and mental health professionals CRCPG therapists about a caseyour care. During a consultation, I make every effort to avoid revealing the identity of my patientshe will conceal your actual identity, as well as any other identifying information. The other professionals CRCPG therapists 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 authorizationconfidential and all receive regular training about the rules, or a court orderregulations, and ethics of confidentiality. If you are involved in or are contemplating litigationa lawsuit or legal action, you should consult with your attorney records may be subject to determine whether a court would be likely to or administrative order me to disclose informationor a subpoena. If a government agency is requesting the information for health oversight activities, I Your therapist may be required to provide it for themthe requested information. If a patient files a complaint you communicate an imminent threat of serious physical harm to yourself or lawsuit against meto an identifiable victim, I the therapist may be required to disclose relevant confidential information regarding that patient to defend myself. There are some situations in which I am legally obligated order to take protective 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 actions may include initiating hospitalization, contacting a family physician or psychiatrist, contacting the police for a safety check, notifying the potential victim, or contacting family members or others who can assist in my practice: providing protection. If I have reason the therapist has reasonable cause to believe that a child, adolescent, child or vulnerable a dependent adult to whom she has provided professional services 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 she file a report with the appropriate government agency, usually the local office of the Department of Social Human Services. Once such a report is filed, I she may be required to provide additional information. If The therapist is legally obligated to release your protected health information in circumstances noted on the Couples Counseling When I know that work with a patient has a propensity for violence and couple, I consider your relationship to be the patient indicates that he/she has client. During the intention to inflict imminent physical injury upon a specified victim(s)course of our work, I may be required to take protective actionssee one of you individually for one or more sessions or for part of a session. 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 sessions should be viewed as part of the patient and/or informing work that I am doing with the potential victim or the police about the threatcouple unless otherwise indicated. If I believe Please know that there anything we discuss when your partner 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 not present may be required disclosed to take appropriate protective actionsthem if, including initiating hospitalizations and/or notifying family members or others in my best judgment, doing so is necessary to effectively help your relationship. Thus, if you feel it necessary to talk about matters that you absolutely want to be shared with no one, you might want to consult with an individual therapist who can protect treat you individually. This “no secrets” policy is intended to allow me to continue to treat the patientcouple by preventing, to the extent possible, a conflict of interest to arise. If such a situation arisesOther than that, 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. 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 disclose confidential information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards treatment to anyone else unless all persons who participate in 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 provide permission 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, release 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. HIPAA provides you with expanded rights 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. 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.
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Limits of Confidentiality. The law protects In general, the privacy of all communications between a patient client and a psychologist. In most situationstherapist or psychologist is protected by law, I and we can only release information about your treatment our work to others if with your written permission. But, there are a few exceptions: In most legal proceedings, you sign have the right to prevent us from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland lawjudge may order our testimony. However, in the following situations, no authorization such an order is required: I may occasionally find it helpful unlikely. We would advise you never to consult other health and mental health professionals about a case. During a consultation, I make every effort agree to avoid revealing the identity any release 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 first discussing it 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 to defend myselfus. 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 others from harm and I may harm, even if we have to reveal some information about a patientclient’s treatment. These situations are unusual in my practice: If I have reason to For example, if we believe that a child, adolescentelderly person or disabled person is being abused, 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 we must file a report with the appropriate government state 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 we believe that a patient has a propensity for violence and the patient indicates that he/she has the intention client is threatening bodily harm to inflict imminent physical injury upon a specified victim(s)another, 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 the patient and/or informing the potential victim or the police about the threatfor our clients. If I believe that there is an imminent risk that a patient will inflict serious physical client threatens harm or death on himto herself/herselfhimself, 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 a higher level of care including hospitalization, including initiating hospitalizations and/or notifying to contact family members or others who can protect the patientmay help provide protection. If such a similar situation arisesoccurs in the course of our work together, I we will attempt to fully discuss it with you before taking any action. The prior situations have rarely occurred in our practice. If a similar situation occurs, we will make every effort to fully discuss it with you before taking any action and I action. We may occasionally find it helpful to consult with other professionals about a client in order to provide best care. During a consultation, we make every effort to completely disguise the identity of each client. Consultants are also legally bound to keep information confidential. If you don’t object, we typically will limit my disclosure not tell you about these consultations unless we believe it is important to what is necessaryour work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problemsexceptions to confidentiality, it is important that we to discuss any questions or concerns that you may havehave as we go along. We will be more than happy to discuss these issues with you. Please note, now or in however, that we are not an attorneys, and formal legal advice is sometimes warranted because the future. The laws governing confidentiality can be are quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. The laws and standards (type in name) Signature of the profession require that I keep Protected Health Information parent/guardian (PHIresponsible party) about each client Date (type in their clinical record. In some circumstances, I may keep some information in two sets name) Signature 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 be tested Date (type in name) Signature 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. HIPAA provides you with expanded rights 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. 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 hispsychologist/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.psychometrician Date
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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 New York 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. 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. HIPAA provides you with expanded rights 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. 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.
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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. 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. HIPAA provides you with expanded rights 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. 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.
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Limits of Confidentiality. The law protects the privacy of all communications Communication between a patient client and a psychologist. In most situations, I can only release information about your treatment counselor is confidential to others if you sign a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland the extent of the law. However, there are certain situations that require only that you provide written, advance consent for the release of information concerning what you say in a counseling session. Your signature on this Agreement provides consent for the following situations, no authorization is requiredactivities: I may occasionally find it helpful to consult Consultation with other health and mental health professionals about a your 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 discussed confidential. If you don’t object, I will not tell you about these consultations unless if I feel that it is important to our work together. I will also note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices record. Processing by administrative staff. In most cases, I need to Protect the Privacy of Your Health Information)share protected information with these individuals for administrative purposes, such as scheduling and/or billing. Disclosures Disclosure required by health insurers insurance companies that includes a DSM-5 diagnosis. Serious danger to yourself or others. If a client 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 to the patient or others, or there is a probability of immediate mental or emotional injury to the client. In the event that I reasonably believe that you are discussed elsewhere a danger, physically or emotionally, to yourself or another person, you specifically consent for me to contact the following individuals, in addition to medical and law enforcement personnel: Name Name Name Phone Number Phone Number Phone Number While my present or potential clients might conduct online searches about my practice and/or me, I do not search my clients on Google, YouTube, Facebook, other search engines or online social networking sites. If clients ask me to conduct such searches or review their web sites or profiles and I consider that it may be helpful, I will consider it. If a client files a complaint or lawsuit against me, I will disclose relevant information regarding that client in order to defend myself. I do not accept friend requests from current or former clients on my psychotherapy related profiles or social networking sites due to the fact that these sites can compromise clients' confidentiality and privacy. For the same reason, I request that clients do not communicate with me via any interactive or social networking websites. Disclosure will not be affected by this Agreement. Agreement in the following situations: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmenttherapy, 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 to defend myself. There are some In certain situations in which I am legally obligated to take actionsaction, 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 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 patienttherapy. If such a situation arisescase should arise, 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 Such a situation would be: If I have cause to believe a child under the age of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions 18 has been 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. The laws and standards abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense the profession require law requires that I keep Protected Health Information (PHI) about each client in their clinical recordmake a report to the appropriate governmental agency. In some circumstancesOnce such a report is filed, I may keep some information be required to provide additional information. If I have cause to believe that an elderly or disabled person is in two sets a state 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 lifeabuse, 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 neglect 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 situationsexploitation, the person would have law requires that I make a right report to the appropriate governmental agency. Once such a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There report is filed, I 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. HIPAA provides you with expanded rights regarding clinical records and disclosures of protected health provide additional 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. 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: Professional Services
Limits of Confidentiality. The law protects In general, the privacy of all communications between a patient client and a psychologist. In most situationspsychotherapist is protected by law, and I can only release information about your treatment our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I am required to file a report with the appropriate state agency. If I believe that a client 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 client. If the client 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. These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you sign a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland lawbefore taking any action. 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 consultant is 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 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 havehave at our next meeting. I will be happy to discuss these issues with you if you need specific advice, now or in but formal legal advice may be needed because the future. The laws governing confidentiality can be are quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. 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 If 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. HIPAA provides you with expanded rights 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. 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 elserequest, I will discuss provide you with relevant portions or summaries of 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 togetherstate laws regarding these issues.
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. 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. HIPAA provides you with expanded rights 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. 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: Doctor Client Services Agreement
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. 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. HIPAA provides you with expanded rights 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. 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
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 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. 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. 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. HIPAA provides you with expanded rights regarding 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. 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: Therapist Client Service 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. 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. HIPAA provides you with expanded rights 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. 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 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. The laws 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. 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. 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. HIPAA provides 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 regarding 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. 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: Psychotherapist Patient Agreement
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 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. The laws 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. HIPAA provides you with expanded rights 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 For this agreement, my policies and procedures, and the attached HIPAA notice form. 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.
Appears in 1 contract
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 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. 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. HIPAA provides you with expanded rights regarding 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. 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: Informed Consent 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 Pursuant to confidentiality should prove helpful in informing you about potential problemsHIPAA, it is important that we discuss any questions or concerns that you I 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. 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 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. HIPAA provides you with several new or expanded rights regarding clinical records with regard to 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. 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: Psychological Services 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. 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. HIPAA provides you with expanded rights 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. 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 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. 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. HIPAA provides you with expanded rights 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. 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
Limits of Confidentiality. The law protects I understand that all information regarding this work will remain confidential and will not be shared with others outside Trinity Wholistic Healing Services, LLC/Xxxxx Xxxxxx, LCSW-C and other interagency approved persons or agencies without my consent. I understand that there are conditions under which this confidentiality must be broken and information be shared with the privacy appropriate individuals. These conditions are as follows: a. If there is suspicion that a child is being abused; b. If there is evidence of physical abuse of elder or dependent adult; c. If I am making serious physical threats against others or myself. I understand that in cases of medical emergency, information sufficient to resolve the situation may be disclosed to emergency personnel, and I will be informed of this disclosure as soon as feasible. I understand that Trinity Wholistic Healing Services, LLC/Xxxxx Xxxxxx, LCSW-C is committed to protecting my health information and that they follow the HIPAA guidelines for disclosing and protecting my PHI (private health information). I understand that a full copy of the HIPAA rules and regulations will be provided to me upon my request. Initial here: I assign payment of all communications between a patient and a psychologistinsurance benefits under all existing insurance policies to Trinity Wholistic Healing Services, LLC/Xxxxx Xxxxxx, LCSW-C, including funds payable to an attorney involved in the claim (if applicable). In most situations, I can only release information about your treatment to others if you sign a consent form the event that meets certain legal requirements imposed services are provided and are not covered 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 objectinsurance plans, I will not tell you about be responsible for payment for these consultations unless I feel that it is important to our work togetherservices. I understand that Trinity Wholistic Healing Services, LLC/Xxxxx Xxxxxx, LCSW-C submits claims directly to my insurance company on my behalf. I understand that I AM RESPONSIBLE TO INSURE THAT CLAIMS ARE PAID BY MY INSURANCE COMPANY. Initial here: I understand that my co-payment, coinsurance and or deductibles are due at the time services are rendered. I understand that my insurance plans may have certain limitations on mental health benefits in the form of pre-certification, number of visits allowed or dollar amount per policy year as well as lifetime maximum benefits. I agree to accept full responsibility for charges once limitations have been reached. At any time during treatment, should I or my child(ren) become ineligible for insurance coverage, I will note notify Trinity Wholistic Healing Services, LLC/Xxxxx Xxxxxx, LCSW-C and understand that I will become responsible for 100% of the bill. I understand that I am financially responsible for all consultations charges whether or not paid by said insurance. Unless specific arrangements are made in your Clinical Record advance a delinquent account (which is called “PHI” over 90 days past due) will result in my Notice of Psychologist’s Policies and Practices account being turned over to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreementcollections. If you are involved referred to collections, Trinity Wholistic Healing Services, LLC/Xxxxx Xxxxxx, LCSW-C reserves the right to charge a collection fee ranging from $29.95 up to 50% depending on the amount that is due and my timeliness in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by paying 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 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 informationpast due amount. If I know that pay for services with 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)personal check, I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan understand 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 be charged a $35.00 returned check fee, if my disclosure to what check is necessaryreturned by my financial institution/bank. 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. 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. HIPAA provides you with expanded rights 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. 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.Initial here:
Appears in 1 contract
Samples: Consent for Treatment and Confidentiality 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. 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. 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. HIPAA provides you with expanded rights 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. 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.
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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 Pursuant to confidentiality should prove helpful in informing you about potential problemsHIPAA, it is important that we discuss any questions or concerns that you I 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. 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 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. HIPAA provides you with several new or expanded rights regarding clinical records with regard to 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. 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.
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Samples: Psychological Services Agreement
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. 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. HIPAA provides you with expanded rights 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. 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
Limits of Confidentiality. The law protects In general, the privacy of all communications between a patient client and a psychologist. In most situationspsychotherapist is protected by law, and I can only release information about your treatment our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I am required to file a report with the appropriate state agency. If I believe that a client 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 client. If the client 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. These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you sign a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland lawbefore taking any action. 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 consultant is 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 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 havehave at our next meeting. I will be happy to discuss these issues with you if you need specific advice, now or in but formal legal advice may be needed because the future. The laws governing confidentiality can be are quite complex, and I am not an attorney. In situations where specific advice is requiredIf you request, formal legal advice I will provide you with relevant portions or summaries of the state laws regarding these issues. Communication between your behavioral health provider(s) and your primary care physician (PCP) may be neededimportant to ensure the continuity of care and that all care is complete, comprehensive, and well-coordinated. The laws and standards of the profession require that I keep however, I will not do so without your consent. Federal regulations (HIPPA) allow me to use or disclose Protected Health Healthcare Information (PHI) about each client from your records in their clinical recordorder to provide treatment to you, to obtain payment for the services I provide, and for other professional activities known as “healthcare operations”. In some circumstancesNevertheless, I ask your consent in order to make this permission explicit. The Notice of Privacy Practices describes these disclosures in more detail. You have the right to review the Notice of Privacy Practices before signing this consent. I reserve the right to revise my Notice of Privacy Practices at any time. You may keep some ask me to restrict the use and disclosure of certain 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 record that otherwise would be disclosed for treatment, progress towards the goalspayment, your medical treatment and social historyor health care operations; however, past treatment records I receive from other providersdo not have to agree to these restrictions. If I do agree to a restriction, reports of professional consultations, billing records, and any reports to insurance carriers or othersthat agreement is binding. You may choose, revoke this consent at any time by giving written notification. Such revocation will not affect any action taken in writing, reliance on the consent prior to examine and/or receive a copy of your clinical recordthe revocation. 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 This consent 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 voluntary; you may reveal refuse to me that sign it. However, I am permitted to refuse to provide healthcare services if this consent is not required granted, or if the consent is later revoked. I hereby consent 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 the use or disclosure of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization my Protected Health Information 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. HIPAA provides you with expanded rights 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. 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 togetherspecified above.
Appears in 1 contract
Limits of Confidentiality. The law protects the privacy of all communications between psychologist-client relationship is confidential. You may expect that anything you say to me will be held in confidence, except when otherwise allowed, including: • If you provide express written consent that your information may be shared. • If there is reasonable cause to suspect that a patient and a psychologist. In most situationschild is being abused or neglected, I can only release must be report this information about your treatment to others if you sign a consent form the Department of Children and Families (DCF) and/or police. • If there is reasonable cause to suspect that meets certain legal requirements imposed by HIPAA and/or Maryland law. However, in the following situations, no authorization an elder or dependent adult is required: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultationbeing abused or neglected, I make every effort must be report this information to avoid revealing the identity of my patientappropriate agency. The other professionals are also legally bound • If there is reason to keep the information confidential. If believe that you don’t objector your child may cause serious harm to yourself/themselves or to another person, I will not tell you about these consultations unless I feel that it is important to our work togethertake protective actions. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice These may include contacting family members, seeking hospitalization, notifying any potential victims of Psychologist’s Policies and Practices to Protect violence, and/or notifying the Privacy of Your Health Information)police. 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 proceeding, you understand that your diagnosis and treatment, such information is protected by the psychologistpsychotherapist-patient client privilege law. I Xxxxx Xxxx, LLC, cannot provide any information without without: o You or your personal representative’s written authorizationauthorization o Receipt of a subpoena with documentation of satisfactory assurances of notice to the client (your) and a certification that no objection was made by the client, or a that the time for filing an objection has elapsed, and no objection was filed, or all objections filed were resolved by the court, and the disclosures are consistent with the resolution; or o 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 to them. If a patient files a complaint you have any questions regarding this consent form or lawsuit against meabout the services offered, you may request to discuss them at any time. By signing below, you are indicating that you have read and understand the above statements: I consent to participate in evaluation and treatment offered to me by Xxxxx Xxxx, LLC. I understand that I may disclose relevant information regarding that patient to defend myselfstop treatment at any time. 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 also reviewed the notice of Privacy Practices and was offered a copy. Client Name (or Legal Guardian) Signature of Client/Guardian Date Xxxxx X. Xxxx, Psy.D. Provider Name Provider Signature Date Provider Use Only: Due to believe that a childlimited capacity with reading, adolescent, or vulnerable adult client has been subjected signed consent after discussing consent verbally and agreeing 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 Servicesservices. 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 Consenting party was not present for the patient’s emergency health care needsevaluation, I may be required to take appropriate protective actions, including initiating hospitalizations and/or notifying family members but legally responsible party was contacted by telephone for verbal consent for treatment 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. 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. HIPAA provides you with expanded rights regarding clinical records and disclosures of protected health information. These include requesting that I amend your recordevaluation; 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. 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 togetherexpress verbal consent was provided.
Appears in 1 contract
Samples: Client Consent and Agreement for Psychological Services
Limits of Confidentiality. The law protects laws that protect the privacy confidentiality of all communications between a patient and a psychologistpersonal information also apply to telehealth. In most situationsAs such, I can only release the information about your treatment to others if you sign a consent form that meets certain legal requirements imposed by HIPAA and/or Maryland lawdisclosed during the course of sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where my mental or emotional state is an issue in a legal proceeding. The dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without written consent from the client. Aprendamos/Alegria Family Counseling will bill insurance for telehealth services when these services have been determined to be covered by a client’s insurance plan. In the event that insurance does not cover telehealth, the client may pay out-of-pocket. A statement of service may be provided to submit to the insurance company if requested. It is the clients responsibility to confirm with their insurance carrier if telehealth services are covered. I have read this document carefully and understand the risks and benefits related to the use of telehealth services. My questions regarding telehealth services have been answered to my satisfaction. I hereby give my informed consent to participate in the following situations, no authorization is required: I may occasionally find it helpful to consult other health and mental health professionals about a caseuse of telehealth services for treatment under the terms described. During a consultationBy my signature below, I make every effort hereby state that I have read, understood, and agree to avoid revealing the identity terms of my this document. _ _ Email Address _ _ Print Name _ _ Client’s Signature Date _ _ Parent or Guardian Signature Date _ _ Clinician Signature Date Failure to keep your scheduled appointments at Alegria Family Counseling (AFC) hinders our ability to provide the best care to our patients. We ask that you show us consideration by calling at least 24 hours prior to your appointment if you are unable to attend. Please call Alegria Family Counseling at: (000) 000-0000 with your notification. This will allow us the opportunity to offer that appointment to another patient. The Repeated late cancellations or no-shows are disruptive to the optimal delivery of care to you and our other professionals are also legally bound to keep clients. Missed appointments prevent other patients from coming in at 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 same time and Practices to Protect affect 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 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. 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 consistency of your clinical recordown treatment program. 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 Appointments cancelled within 24 hours of $.60 per page scheduled service will be chargeddocumented as no show. There may be other associated costs for review of recordsAs a result, three (3) consecutive late cancellations and or no shows will result in discontinuing services at AFC. The other set I keep in some instances is a set of psychotherapy notes. These notes Late cancellations due to illness or family emergency 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 excluded 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. HIPAA provides you with expanded rights 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. 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 togetherpolicy.
Appears in 1 contract
Samples: Informed Consent Contract
