Common use of LIMITS ON CONFIDENTIALITY Clause in Contracts

LIMITS ON 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 that meets certain legal requirements imposed by HIPAA and/or Virginia law. I will always take every precaution and measure to insure the privacy of your confidential information. There are some situations in which a psychologist is legally obligated to take some action that will likely involve revealing information to an outside party, possibly without your consent. These situations are unusual, and are limited to cases in which harm is likely, including: • Cases in which a psychologist is ordered by a judge to release therapy records • Cases in which a psychologist has reason to believe a child under 18 may be abused or neglected • Cases in which a psychologist has reason to believe an adult over the age of 60 has been abused or neglected in the preceding 12 months • Cases in which you have made a specific threat of violence against another, or if a psychologist believes that you present a clear, imminent risk of serious physical harm to another or yourself If such a situation arises, I will make every effort to fully discuss it with you before taking any action or releasing any information about you, and I will limit disclosure of information to only what is necessary. Confidentiality issues can be complicated, so if you have any questions about them, please feel free to ask them now or in the future as needed. In addition, I want to protect your privacy if I happen to run into you in a public setting. If this occurs, I will not acknowledge you. This will give you the option of remaining anonymous. If you speak first, I'll be happy to say 'hello.' PATIENT RIGHTS HIPAA provides you with a number of rights, which briefly include the right to Amend the information in your record, to limit what information is disclosed and to whom, to request restrictions as to how you are contacted, and to receive an Accounting of Disclosures, or a list of all information that has been released about you. You also can file a complaint about our policies and procedures regarding your records with the federal Department of Health and Human Services.

LIMITS ON 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 that meets certain legal requirements imposed by HIPAA and/or Virginia law. I will always take every precaution and measure to insure the privacy of your confidential information. There are some situations in which a psychologist is legally obligated to take some action that which will likely involve revealing information to an outside party, possibly without your consent. These situations are unusual, and are limited to cases in which harm is likely, including: • Cases in which a psychologist is ordered by a judge to release therapy records • Cases in which a psychologist has reason to believe a child under 18 may be abused or neglected • Cases in which a psychologist has reason to believe an adult over the age of 60 has been abused or neglected in the preceding 12 months • Cases in which you have made a specific threat of violence against another, or if a psychologist believes that you present a clear, imminent risk of serious physical harm to another or yourself If such a situation arises, I will make every effort to fully discuss it with you before taking any action or releasing any information about you, and I will limit disclosure of information to only what is necessary. Confidentiality issues can be complicated, so if you have any questions about them, please feel free to ask them now or in the future as needed. In addition, I want to protect your privacy if I happen to run into you in a public setting. If this occurs, I will not acknowledge you. This will give you the option of remaining anonymous. If you speak first, I'll be happy to say 'hello.' PATIENT RIGHTS HIPAA provides you with a number of rights, which briefly include the right to Amend the information in your record, to limit what information is disclosed and to whom, to request restrictions as to how you are contacted, and to receive an Accounting of Disclosures, or a list of all information that has been released about you. You also can file a complaint about our policies and procedures regarding your records with the federal Department of Health and Human Services.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychologist/psychiatrist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA and/or Virginia Illinois law. In many cases, I will always take every precaution ask that you sign a BPA/BCA form to release information, even if you have already completed a form designed by another individual/agency. However, in some situations, no authorization is required. At BPA/BCA, we will follow both HIPAA and measure Illinois law with regard to insure the privacy of your confidential protecting and releasing information. If you have questions about a specific confidentiality issue, please feel free to ask. There are some situations in which a psychologist is I am legally obligated to take actions which I believe are necessary to attempt to protect you or others from harm, and I may have to reveal some action that will likely involve revealing information to an outside party, possibly without your consentabout a patient’s treatment. These situations are unusual, and are limited to cases unusual in which harm is likely, including: my practice. • Cases in which a psychologist is ordered by a judge to release therapy records • Cases in which a psychologist has reason If I have reasonable cause to believe that a child under 18 known to me in my professional capacity may be an abused or neglected child, the law requires that I file a report with the local office of the Department of Children and Family Services. • Cases in which a psychologist has If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months months, the law requires that I file a report with the agency designated to receive such reports by the Department of Aging. • Cases in which If you have made a specific threat of violence against another, another or if a psychologist believes I believe that you present a clear, imminent risk of serious physical harm to another another, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police or yourself seeking hospitalization. • If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action or releasing any information about youaction, as appropriate, and I will limit my disclosure of information to only what is necessary. Confidentiality issues can be complicatedWhile this written summary of exceptions to confidentiality should prove helpful in informing you about potential actions, so if you have it is important that we discuss any questions about them, please feel free to ask them or concerns that you may have now or in the future as 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. In additionPROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Healthcare Information (PHI) about you in your Clinical Record. Professional records can be misinterpreted and/or upsetting to untrained readers. For this reason, I want recommend that if you need your records, that you review them in the presence of a designated member of our staff or have them forwarded directly to protect another health professional. Please note that Psychotherapy Notes may not be released without an appropriately completed Authorization. MINORS AND PARENTS Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patient between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain treatment information. If everyone agrees, during treatment, I will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. I may also provide parents with a summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Fees for professional services are listed in our fee schedule. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your privacy if account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, BPA/BCA has the option of using legal means to secure the payment. This may involve using our collection agency which will require me to disclose otherwise confidential information. In most collection situations, the only information I happen release regarding a patient’s treatment is his/her name, address, employment information, and telephone numbers, the nature of services provided and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT (BPA Patients) In order for us to run into set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. For insurance carriers that I am in-plan, I will fill out and submit forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can, based on 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 will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plan such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a public settingperson’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this occursis the case, you have the option of paying for my services on your own or I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will not acknowledge youmake every effort to release only the minimum information about you that is necessary for the purpose requested. This information will give you become part of the option of remaining anonymousinsurance company files and will probably be stored in a computer. If you speak firstThough all insurance companies claim to keep such information confidential, I'll be happy to say 'hello.' PATIENT RIGHTS HIPAA provides I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a number copy of rightsany report I submit, which briefly include if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to Amend pay for my services by yourself to avoid the information in your record, to limit what information is disclosed and to whom, to request restrictions as to how you are contacted, and to receive an Accounting of Disclosures, or a list of all information that has been released about youproblems described above (unless prohibited by contract). You also can file a complaint about our policies and procedures regarding your records with the federal Department of Health and Human Services.AGREEMENT (BCA AND BPA Patients)

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychologist/therapist/ psychiatrist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA and/or Virginia Illinois law. In many cases, I will always take every precaution ask that you sign a BPA form to release information, even if you have already completed a form designed by another individual/agency. However, in some situations, no authorization is required. At BPA, we will follow both HIPAA and measure Illinois Law with regard to insure the privacy of your confidential protecting and releasing information. If you have questions about a specific confidentiality issue, please feel free to ask. There are some situations in which a psychologist is I am legally obligated to take actions which I believe are necessary to attempt to protect you or others from harm, and I may have to reveal some action that will likely involve revealing information to an outside party, possibly without your consentabout a patient’s treatment. These situations are unusual, and are limited to cases unusual in which harm is likely, including: • Cases in which a psychologist is ordered by a judge to release therapy records • Cases in which a psychologist has reason my practice.  If I have reasonable cause to believe that a child under 18 known to me in my professional capacity may be an abused or neglected • Cases in which child, the law requires that I file a psychologist has report with the local office of the Department of Children and Family Services.  If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months • Cases in which months, the law requires that I file a report with the agency designated to receive such reports by the Department of Aging.  If you have made a specific threat of violence against another, another or if a psychologist believes I believe that you present a clear, imminent risk of serious physical harm to another another, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police or yourself seeking hospitalization.  If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action or releasing any information about youaction, as appropriate, and I will limit my disclosure of information to only what is necessary. Confidentiality issues can be complicatedWhile this written summary of exceptions to confidentiality should prove helpful in informing you about potential actions, so if you have it is important that we discuss any questions about them, please feel free to ask them or concerns that you may have now or in the future as 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. In additionPROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Healthcare Information (PHI) about you in your Clinical Record. Professional records can be misinterpreted and/or upsetting to untrained readers. For this reason, I want recommend that if you need your records, that you review them in the presence of a designated member of our staff or have them forwarded directly to protect another health professional. Please note that Psychotherapy Notes may not be released without an appropriately completed Authorization. MINORS AND PARENTS Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patient between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain treatment information. If everyone agrees, during treatment, I will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. I may also provide parents with a summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Fees for professional services are listed in our fee schedule. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your privacy if account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, BPA has the option of using legal means to secure the payment. This may involve using our collection agency which will require me to disclose otherwise confidential information. In most collection situations, the only information I happen release regarding a patient’s treatment is his/her name, address, employment information, and telephone numbers, the nature of services provided and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT (BPA Patients) In order for us to run into set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. For insurance carriers that I am in-plan, I will submit forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can, based on 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 will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plan such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a public settingperson’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this occursis the case, you have the option of paying for my services on your own or I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will not acknowledge youmake every effort to release only the minimum information about you that is necessary for the purpose requested. This information will give you become part of the option of remaining anonymousinsurance company files and will probably be stored in a computer. If you speak firstThough all insurance companies claim to keep such information confidential, I'll be happy to say 'hello.' PATIENT RIGHTS HIPAA provides I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a number copy of rightsany report I submit, which briefly include if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to Amend pay for my services by yourself to avoid the information in your record, to limit what information is disclosed and to whom, to request restrictions as to how you are contacted, and to receive an Accounting of Disclosures, or a list of all information that has been released about youproblems described above (unless prohibited by contract). You also can file a complaint about our policies and procedures regarding your records with the federal Department of Health and Human Services.AGREEMENT (BPA Patients)

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychologist/therapist/ psychiatrist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA and/or Virginia Illinois law. In many cases, I will always take every precaution ask that you sign a BPA/BCA form to release information, even if you have already completed a form designed by another individual/agency. However, in some situations, no authorization is required. At BPA/BCA, we will follow both HIPAA and measure Illinois law with regard to insure the privacy of your confidential protecting and releasing information. If you have questions about a specific confidentiality issue, please feel free to ask. There are some situations in which a psychologist is I am legally obligated to take actions which I believe are necessary to attempt to protect you or others from harm, and I may have to reveal some action that will likely involve revealing information to an outside party, possibly without your consentabout a patient’s treatment. These situations are unusual, and are limited to cases unusual in which harm is likely, including: my practice. • Cases in which a psychologist is ordered by a judge to release therapy records • Cases in which a psychologist has reason If I have reasonable cause to believe that a child under 18 known to me in my professional capacity may be an abused or neglected child, the law requires that I file a report with the local office of the Department of Children and Family Services. • Cases in which a psychologist has If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months months, the law requires that I file a report with the agency designated to receive such reports by the Department of Aging. • Cases in which If you have made a specific threat of violence against another, another or if a psychologist believes I believe that you present a clear, imminent risk of serious physical harm to another another, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police or yourself seeking hospitalization. • If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action or releasing any information about youaction, as appropriate, and I will limit my disclosure of information to only what is necessary. Confidentiality issues can be complicatedWhile this written summary of exceptions to confidentiality should prove helpful in informing you about potential actions, so if you have it is important that we discuss any questions about them, please feel free to ask them or concerns that you may have now or in the future as 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. In additionPROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Healthcare Information (PHI) about you in your Clinical Record. Professional records can be misinterpreted and/or upsetting to untrained readers. For this reason, I want recommend that if you need your records, that you review them in the presence of a designated member of our staff or have them forwarded directly to protect another health professional. Please note that Psychotherapy Notes may not be released without an appropriately completed Authorization. MINORS AND PARENTS Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patient between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain treatment information. If everyone agrees, during treatment, I will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. I may also provide parents with a summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Fees for professional services are listed in our fee schedule. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your privacy if account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, BPA/BCA has the option of using legal means to secure the payment. This may involve using our collection agency which will require me to disclose otherwise confidential information. In most collection situations, the only information I happen release regarding a patient’s treatment is his/her name, address, employment information, and telephone numbers, the nature of services provided and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT (BPA Patients) In order for us to run into set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. For insurance carriers that I am in-plan, I will submit forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can, based on 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 will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plan such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a public settingperson’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this occursis the case, you have the option of paying for my services on your own or I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will not acknowledge youmake every effort to release only the minimum information about you that is necessary for the purpose requested. This information will give you become part of the option of remaining anonymousinsurance company files and will probably be stored in a computer. If you speak firstThough all insurance companies claim to keep such information confidential, I'll be happy to say 'hello.' PATIENT RIGHTS HIPAA provides I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a number copy of rightsany report I submit, which briefly include if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to Amend pay for my services by yourself to avoid the information in your record, to limit what information is disclosed and to whom, to request restrictions as to how you are contacted, and to receive an Accounting of Disclosures, or a list of all information that has been released about youproblems described above (unless prohibited by contract). You also can file a complaint about our policies and procedures regarding your records with the federal Department of Health and Human Services.AGREEMENT (BCA AND BPA Patients)

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient client and a psychologistpsychotherapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA and/or Virginia law. I will always take every precaution and measure to insure the privacy of your confidential informationform. There are some situations where I am permitted or required to disclose information without either your consent or authorization. Please see the attached “Notice of Policies and Practices to Protect the Privacy of Your Health Information” for more information. A summary is provided below: ▪ If a client threatens to harm himself/herself or others, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. ▪ If you are involved in which a psychologist court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychotherapist-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order signed by the judge requiring it. If you are involved or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. ▪ I am required to comply if a government agency requests information for health oversight activities. ▪ If a client files a complaint or lawsuit against me, I may disclose all relevant information in order to defend myself. I am legally obligated to take some action that will likely involve action, such as making a report to a protective agency or warning a potential victim, which I believe is necessary to protect others from harm, and thereby revealing information to an outside party, possibly without your consentabout a client’s treatment. These situations are unusual, unusual in my practice. I have outlined situations that would legally obligate me to take action: ▪ If I have reasonable cause to suspect a child has suffered harm as a result of child abuse or neglect and are limited to cases in which harm is likely, including: • Cases in which a psychologist is ordered by a judge to release therapy records • Cases in which a psychologist it has reason not already been reported. ▪ If I have reasonable cause to believe a child under 18 vulnerable adult suffers from abandonment, exploitation, abuse, neglect, or self-neglect; or a disabled person has been abused. ▪ If a client communicates an immediate threat of serious harm to an identifiable victim, I may be abused or neglected • Cases in which a psychologist has reason required to believe an adult over notify the age of 60 has been abused or neglected in potential victim, contact the preceding 12 months • Cases in which you have made a specific threat of violence against anotherpolice, or if a psychologist believes that you present a clear, imminent risk of serious physical harm to another or yourself and/or seek hospitalization for the client. If any such a situation arises, I will make every effort to fully discuss it with you before taking any action or releasing any information about youaction, and I will try to limit my disclosure of information to only what is necessary. Confidentiality issues can be complicatedWhile this written summary of exceptions of confidentiality should prove helpful in informing you about potential problems, so if you have it is important that we discuss any questions about them, please feel free to ask them or concerns that you may have now or in the future as neededfuture. The laws governing confidentiality can be quite complex, and I am not an attorney. In additionsituations where specific advice is required, I want to protect your privacy if I happen to run into you in a public setting. If this occurs, I will not acknowledge you. This will give you the option of remaining anonymous. If you speak first, I'll formal legal advice may be happy to say 'helloneeded.' PATIENT RIGHTS HIPAA provides you with a number of rights, which briefly include the right to Amend the information in your record, to limit what information is disclosed and to whom, to request restrictions as to how you are contacted, and to receive an Accounting of Disclosures, or a list of all information that has been released about you. You also can file a complaint about our policies and procedures regarding your records with the federal Department of Health and Human Services.