Common use of Limits to Confidentiality Clause in Contracts

Limits to Confidentiality. The law protects the privacy of all communications between a patient and a mental health provider. In most situations, we can only release information about your treatment or assessment to others if you sign a written Authorization. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows: • Clinical information about your case may be shared fully within WCU CMHS by the students enrolled in clinic practicum and staff/faculty for educational, evaluation and therapeutic purposes. If clinical staff present case information at professional conferences, the information will be disguised such that it is impossible to link the information to you or your family. • We employ administrative staff who have access to some of your protected information for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of WCU CMHS. • On occasion, WCU CMHS may find it helpful to consult with another health or mental health professional. During such a consultation, every effort is made to avoid revealing the identity of the patient. The other professional is legally bound to keep the information confidential. All consultations are noted in the patient record. • If a patient seriously threatens to harm him/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 your consent or authorization: • If you are involved in a court proceeding and a request is made for information concerning the professional services we provided to you, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. • If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. • If a patient files a complaint or lawsuit against WCU CMHS, we may disclose relevant information regarding that patient as part of our defense. • If we are treating a patient who files a worker’s compensation claim, we may, upon appropriate request, be required to provide otherwise confidential information to the employer. There are some situations in which we are legally obligated to take actions to protect others from harm and which may require us to reveal some information about your evaluation/treatment: ▪ If we have reason to believe that a child is the victim of abuse or neglect, the law requires that we file a report with the Pennsylvania Department of Child Welfare (i.e. ChildLine). Once such a report is filed, we may be required to provide additional information. ▪ If we have reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we are required to report this to the Pennsylvania Department of Aging. Once such a report is filed, we may be required to provide additional information. ▪ If we believe that a patient presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to carry out the threat or intent, we are required to take protective actions, such as warning the potential victim, contacting the police, or initiating proceedings for hospitalization. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit 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. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information (PHI) about you in your Clinical Record for six (6) years. You may request in writing to examine and/or receive a copy of your Clinical Record, except in unusual circumstances, such as 1) danger to yourself and/or others, 2) where information has been supplied to us confidentially by others, or 3) the record makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to the other person,. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your student clinician, or have them forwarded to another mental health professional so you can discuss the contents. We do not provide copies of testing protocols or test scores directly to patients; however we will provide them to another professional if requested. In most circumstances, we are allowed to charge a fee to cover any expenses incurred providing this information. If we refuse your request for access to your records, you have a right of review (except for information that has been supplied to us confidentially by others). PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment/evaluation records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, we may request an agreement from parents that they consent to give up access to their child’s records. If they agree, during treatment we will provide parents with only general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. RESEARCH WCU CMHS also serves as a site for clinical research conducted by doctoral students and faculty. Patients may be approached for participation in research studies that have received prior approval from the West Xxxxxxx University Institutional Review Board. Prior to any research participation, a separate informed consent fully explaining the study must be provided, and you can choose either to participate or not to participate. You will never be penalized for choosing not to participate in research (i.e., services to which you are ordinarily entitled will not be withheld if you choose not to participate in any research study).

Limits to Confidentiality. The law protects the privacy of all communications between a patient and a mental health providerpsychologist. In most situations, we can only release information about your treatment or assessment to others if you sign a written Authorization. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows: •  Clinical information about your case may be shared fully within the WCU CMHS clinic by the students enrolled in clinic practicum and staff/faculty for educational, evaluation educational and therapeutic purposes. If clinical staff present case information at professional conferences, the information will be disguised such that it is impossible to link the information to you or your family. •  We employ administrative staff who have access to some of your protected information for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of WCU CMHSthe clinic. •  On occasion, WCU CMHS the clinic may find it helpful to consult with another health or mental health professional. During such a consultation, every effort is made to avoid revealing the identity of the patientclient. The other professional is legally bound to keep the information confidential. All consultations are noted in the patient client record. •  If a patient client seriously threatens to harm him/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 your consent or authorizationAuthorization: •  If you are involved in a court proceeding and a request is made for information concerning the professional services we provided to you, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. •  If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. •  If a patient client files a complaint or lawsuit against WCU CMHSthe clinic, we may disclose relevant information regarding that patient client as part of our defense. •  If we are treating a patient client who files a worker’s compensation claim, we may, upon appropriate request, be required to provide otherwise confidential information to the employer. There are some situations in which we are legally obligated to take actions to protect others from harm and which may require us to reveal some information about a your evaluation/treatment: ▪  If we have reason to believe that a child is the victim of abuse or neglect, the law requires that we file a report with the Pennsylvania Department of Child Welfare (i.e. ChildLine). Once such a report is filed, we may be required to provide additional information. ▪  If we have reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we are required to report this to the Pennsylvania Department of Aging. Once such a report is filed, we may be required to provide additional information. ▪  If we believe that a patient client presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to carry out the threat or intent, we are required to take protective actions, such as warning the potential victim, contacting the police, or initiating proceedings for hospitalization. hospitalization If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit 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. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information (PHI) about you in your Clinical Record for six (6) years. You may request in writing to examine and/or receive a copy of your Clinical Record, except Except in unusual circumstances, such as 1) circumstances that involve danger to yourself and/or others, 2) others or where information has been supplied to us confidentially by others, or 3) the record makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to the such other person,, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your student cliniciantherapist, or have them forwarded to another mental health professional so you can discuss the contents. We do not provide copies of testing protocols or test scores directly to patients; however we will provide them to another professional if requested. In most circumstances, we are allowed to charge a fee to cover any expenses incurred providing this information. If we refuse your request for access to your records, you have a right of review (except for information that has been supplied to us confidentially by others), which your therapist will discuss with you upon request. PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment/evaluation treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, we may request an agreement from parents that they consent to give up access to their child’s records. If they agree, during treatment we will provide parents them with only general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. RESEARCH WCU CMHS also serves as a site for clinical research conducted by doctoral students and faculty. Patients may be approached for participation in research studies that have received prior approval from the West Xxxxxxx University Institutional Review Board. Prior to any research participation, a separate informed consent fully explaining the study must be provided, and you can choose either to participate or not to participate. You will never be penalized for choosing not to participate in research (i.e., services to which you are ordinarily entitled will not be withheld if you choose not to participate in any research study).

Limits to Confidentiality. The law protects Necessary case information is shared with those inside the privacy of all communications between a patient Clinic for training, supervision, and a mental health providerresearch as described above and to provide professional services (such as for clinical case supervision, consultation, training, and teaching). In most situationsClinic administrative personnel also have access to client records for program evaluation and planning, we can only release and for case management. Non-identifying information about your treatment or assessment to others if you sign a written Authorization. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows: • Clinical information about your case may be shared fully within WCU CMHS with other professionals outside of the Clinic if case consultation is required. You may wish to discuss with your student-therapist how to handle chance encounters in public. When your case with your student-therapist is terminated (case completion, graduation, transfer, etc.), future contact with him/her is discouraged. Also, please respect the confidentiality of other clients you may see in the waiting areas of the Clinic. Information about clients may be disclosed to those outside of the Clinic for any of the following reasons: 1) a completed Release of Information is authorized by the students enrolled client or guardian in clinic practicum and staff/faculty for educational, evaluation and therapeutic purposes. If clinical staff present case writing; 2) the client has completed an informed consent to participate in research that requires designated information at professional conferences, from the information will be disguised such record; 3) a valid court order mandates the release of records; 4) the client is a danger to self or others; 5) reason to believe that it is impossible to link the information to you there has been abuse or your family. • We employ administrative staff who have access to some neglect of your protected information for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of WCU CMHS. • On occasion, WCU CMHS may find it helpful to consult with another health or mental health professional. During such a consultation, every effort is made to avoid revealing the identity of the patient. The other professional is legally bound to keep the information confidential. All consultations are noted in the patient record. • If a patient seriously threatens to harm him/herself, we may be obligated to seek hospitalization for him/herchild, or to contact family members abuse of an elderly, vulnerable, or others who can help provide protection. There disabled person; 6) certain communicable diseases are some situations where we are permitted or required to disclose information without your consent be disclosed to the local health department; 7) the client privilege for privacy in court has been waived; 8) the client initiates a complaint or authorization: • If you are involved in a court proceeding and a request is made for information concerning legal proceedings against the professional services we provided to you, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. • If Clinic; 9) a government agency is requesting the requests information for health oversight activities, we may be required to provide it for them. • If ; 10) a patient files a complaint or lawsuit against WCU CMHS, we may disclose relevant information regarding that patient as part of our defense. • If we are treating a patient who client files a worker’s compensation claim, we may, upon appropriate request, ; 11) the Division of Occupational and Professional Licensing mandates the release of records; 12) a coroner or medical examiner requests information required by law; or 13) other disclosures required by law. Only the minimum amount of information necessary to meet the purpose of a request will be required to provide otherwise confidential information to the employer. There are some situations in which we are legally obligated to take actions to protect others from harm and which may require us to reveal some information about your evaluation/treatment: ▪ If we have reason to believe that a child is the victim of abuse or neglect, the law requires that we file a report with the Pennsylvania Department of Child Welfare (i.e. ChildLine). Once such a report is filed, we may be required to provide additional information. ▪ If we have reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we are required to report this to the Pennsylvania Department of Aging. Once such a report is filed, we may be required to provide additional information. ▪ If we believe that a patient presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to carry out the threat or intent, we are required to take protective actions, such as warning the potential victim, contacting the police, or initiating proceedings for hospitalization. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit 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 futuredisclosed. The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards Clinic cannot guarantee that entities outside of our profession require that we keep Protected Health Information (PHI) about you in your Clinical Record for six (6) yearsthe Clinic will honor client confidentiality. You may request in writing to examine and/or receive revoke a copy Release of your Clinical RecordInformation at any time, except in unusual circumstances, such as 1) danger to yourself and/or others, 2) where information has been supplied to us confidentially by others, or 3) the record makes reference to another person (unless such other person is a health care provider) and but we believe that access is reasonably likely to cause substantial harm to the other person,. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your student clinician, or have them forwarded to another mental health professional so you can discuss the contents. We do not provide copies of testing protocols or test scores directly to patients; however we will provide them to another professional if requested. In most circumstances, we are allowed to charge a fee to cover any expenses incurred providing this information. If we refuse your request for access to your records, you have a right of review (except for information that has been supplied to us confidentially by others). PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment/evaluation records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, we may request an agreement from parents that they consent to give up access to their child’s records. If they agree, during treatment we will provide parents with only general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. RESEARCH WCU CMHS also serves as a site for clinical research conducted by doctoral students and faculty. Patients may be approached for participation in research studies that have received prior approval from the West Xxxxxxx University Institutional Review Board. Prior to any research participation, a separate informed consent fully explaining the study must be provided, and you can choose either to participate or not to participate. You will never be penalized for choosing not to participate in research (i.e., services to which you are ordinarily entitled will not be withheld if you choose not able to participate in retract any research study)disclosures that have already been made.

Limits to Confidentiality. The confidentiality of your records is highly valued. The law protects the privacy of all communications between a patient client and a mental health providertherapist, although some situations are excluded by law. In most situations, we I can only release information about your treatment or assessment to others if you sign a written Authorization. There are authorization form that meets certain legal requirements imposed by HIPAA and/or other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows: • Clinical information about your case may be shared fully within WCU CMHS by the students enrolled in clinic practicum and staff/faculty for educational, evaluation and therapeutic purposes. If clinical staff present case information at professional conferences, the information will be disguised such that it is impossible to link the information to you federal or your family. • We employ administrative staff who have access to some of your protected information for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of WCU CMHS. • On occasion, WCU CMHS may find it helpful to consult with another health or mental health professional. During such a consultation, every effort is made to avoid revealing the identity of the patient. The other professional is legally bound to keep the information confidential. All consultations are noted in the patient record. • If a patient seriously threatens to harm him/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 your consent or authorization: • If you are involved in a court proceeding and a request is made for information concerning the professional services we provided to you, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your written authorization, or a court orderstate laws. If you are involved choose to break confidentiality in any way (i.e., sending me an e-mail, applying for insurance reimbursement, telling anyone about your therapy, use an analog cell-phone) I cannot control, or contemplating litigationbe held liable for the outcome. Limits to preserving confidentiality include the following: o If you have a health insurance policy, it will usually provide some coverage for mental health treatment or assessment. If you should consult with choose to use this mental health coverage, your attorney to determine whether a court would be likely to order us to disclose informationinsurance company, external gatekeeper, and quality assurance committee may review your records for quality and/or appropriateness of care. • If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. • If a patient files a complaint or lawsuit against WCU CMHS, we may disclose relevant Required information regarding that patient as part the state of our defensecare may also be released to your insurance company to facilitate payment. • o If we are treating a patient who files a worker’s compensation claim, we may, upon appropriate request, be required to provide otherwise confidential information to the employer. There are some situations in which we are legally obligated to take actions to protect others from harm and which may require us to reveal some information about your evaluation/treatment: ▪ If we I know or have reason to believe suspect that a child under 18 years of age is being or has been abused, abandoned or neglected by a parent, legal custodian, caregiver or any other person responsible for the victim of abuse or neglectchild’s welfare, the law requires mandates that we I file a verbal and written report with the Pennsylvania Department of Child Welfare (i.e. ChildLine)Children and Families. Once such a report is filed, we I may be required to provide additional information. ▪ o If we have reason to I believe that an elderly person or other adult there is in need a clear and immediate probability of protective services (regarding abuse, neglect, exploitation or abandonment), we are required to report this physical harm to the Pennsylvania Department of Aging. Once such a report is filedclient, we other individuals, or to society, I may be required to provide additional information. ▪ If we believe that a patient presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to carry out the threat or intent, we are required disclose information to take protective actionsaction, such as warning including communicating the information to the potential victimvictim(s), contacting and/or appropriate family member(s), and/or the police, or initiating proceedings for hospitalization. o If such a situation arises, we I will make every a reasonable effort to fully discuss it with you before taking any action and we 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 futureI HAVE READ AND I UNDERSTAND THE ABOVE INFORMATION AND BY SIGNING THIS FORM I ACCEPT AND FULLY AGREE TO BE TREATED ACCORDING TO THE ABOVE CONDITIONS AND CLIENT/THERAPIST RESPONSIBILITIES. The laws governing confidentiality can be quite complexI UNDERSTAND I HAVE THE RIGHT TO END TREATMENT AT ANY TIME. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information (PHI) about you in your Clinical Record for six (6) years. You may request in writing to examine and/or receive a copy of your Clinical Record, except in unusual circumstances, such as 1) danger to yourself and/or others, 2) where information has been supplied to us confidentially by others, or 3) the record makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to the other person,. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your student clinician, or have them forwarded to another mental health professional so you can discuss the contents. We do not provide copies of testing protocols or test scores directly to patients; however we will provide them to another professional if requested. In most circumstances, we are allowed to charge a fee to cover any expenses incurred providing this information. If we refuse your request for access to your records, you have a right of review (except for information that has been supplied to us confidentially by others). PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment/evaluation records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, we may request an agreement from parents that they consent to give up access to their child’s records. If they agree, during treatment we will provide parents with only general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. RESEARCH WCU CMHS also serves as a site for clinical research conducted by doctoral students and faculty. Patients may be approached for participation in research studies that have received prior approval from the West Xxxxxxx University Institutional Review Board. Prior to any research participation, a separate informed consent fully explaining the study must be provided, and you can choose either to participate or not to participate. You will never be penalized for choosing not to participate in research (i.e., services to which you are ordinarily entitled will not be withheld if you choose not to participate in any research study).CLIENT SIGNATURE DATE THERAPIST SIGNATURE DATE CONNECTICUT CENTER FOR NATURAL HEALTH

Limits to Confidentiality. The law protects the privacy of all communications between a patient client and a mental health provider. In most situations, we can only release information about your treatment or assessment to others if you sign a written Authorization. There Below are other situations that require only that you provide written, advance consent. Your signature on , which you provide when you sign this agreement provides consent for those activities, as followsagreement: •  Clinical information about your case may be shared fully within the WCU CMHS clinic by the students enrolled in clinic practicum and staff/faculty for educational, educational and evaluation and therapeutic purposes. If clinical staff present case information at professional conferences, the information will be disguised such that it is impossible to link the information to you or your family. •  We employ administrative staff who have access to some of your protected information for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given privacy training about protecting your privacy and have agreed not to release any information outside of WCU CMHSthe clinic. •  On occasion, WCU CMHS the clinic may find it helpful to consult with another health or mental health professional. During such a consultation, every effort is made to avoid revealing the identity of the patientclient. The other professional is legally bound to keep the information confidential. All consultations are noted in the patient client’s clinic record. •  If a patient client seriously threatens to harm himhimself/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 your consent or authorizationAuthorization: •  If you are involved in a court proceeding and a request is made for information concerning the professional services we provided to you, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your 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 us to disclose information. •  If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. •  If a patient client files a complaint or lawsuit against WCU CMHSthe clinic, we may disclose relevant information regarding that patient client as part of our defense. •  If we are treating evaluating a patient client who files a worker’s compensation claim, we may, upon appropriate request, be required to provide otherwise confidential information to the employer. There are some situations in which we are legally obligated to take actions to protect others from harm and which may require us to reveal some information about a your evaluation/treatment: ▪  If we have reason to believe that a child is the victim of abuse or neglect, the law requires that we file a report with the Pennsylvania Department of Child Welfare (i.e. ChildLine). Once such a report is filed, we may be required to provide additional information. ▪  If we have reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we are required to report this to the Pennsylvania Department of Aging. Once such a report is filed, we may be required to provide additional information. ▪  If we believe that a patient client presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to carry out the threat or intent, we are required to take protective actions, such as warning the potential victim, contacting the police, or initiating proceedings for hospitalization. hospitalization If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit 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. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information (PHI) about you in your Clinical Record for six (6) years. You may request in writing to examine and/or receive a copy of your Clinical Record, except Except in unusual circumstances, such as 1) circumstances that involve danger to yourself and/or others, 2) or where information has been supplied to us confidentially by others, or 3) the record makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to the such other person,. Because these are professional records, they can be misinterpreted you may examine and/or upsetting to untrained readers. For this reasonreceive a copy of your Clinical Record, we recommend that if you initially review them with your student clinician, or have them forwarded to another mental health professional so you can discuss the contentsrequest it in writing. We do not provide copies of testing protocols or test scores directly to patientsclients; however we will provide them to another professional if requested. In most circumstances, we are allowed to charge a fee to cover any expenses incurred providing this information. If we refuse your request for access to your records, you have a right of review (except for information that has been supplied to us confidentially by others). PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Record and disclosures of PHIprotected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment/evaluation records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, we may request an agreement from parents that they consent to give up access to their child’s records. If they agree, during treatment we will provide parents with only general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. RESEARCH WCU CMHS also serves as a site for clinical research conducted by doctoral students and faculty. Patients may be approached for participation in research studies that have received prior approval from the West Xxxxxxx University Institutional Review Board. Prior to any research participation, a separate informed consent fully explaining the study must be provided, and you can choose either to participate or not to participate. You will never be penalized for choosing not to participate in research (i.e., services to which you are ordinarily entitled will not be withheld if you choose not to participate in any research study).

Limits to Confidentiality. The law protects the privacy of all communications between a patient and a mental health provider. In most situations, we can only release information about your treatment or assessment to others if you sign a written Authorization. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows: • Clinical information about your case may be shared fully within WCU CMHS by the students enrolled in clinic practicum and staff/faculty for educational, evaluation and therapeutic purposes. If clinical staff present case information at professional conferences, the information will be disguised such that it is impossible to link the information to you or your family. • We employ administrative staff who have access to some of your protected information for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of WCU CMHS. • On occasion, WCU CMHS may find it helpful to consult with another health or mental health professional. During such a consultation, every effort is made to avoid revealing the identity of the patient. The other professional is legally bound to keep the information confidential. All consultations are noted in the patient record. • If a patient seriously threatens to harm him/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 your consent or authorization: • If you are involved in a court proceeding and a request is made for information concerning the professional services we provided to you, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. • If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. • If a patient files a complaint or lawsuit against WCU CMHS, we may disclose relevant information regarding that patient as part of our defense. • If we are treating a patient who files a worker’s compensation claim, we may, upon appropriate request, be required to provide otherwise confidential information to the employer. There are some situations in which we are legally obligated to take actions to protect others from harm and which may require us to reveal some information about your evaluation/treatment: ▪  If we have reason to believe that a child is the victim of abuse or neglect, the law requires that we file a report with the Pennsylvania Department of Child Welfare (i.e. ChildLine). Once such a report is filed, we may be required to provide additional information. ▪  If we have reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we are required to report this to the Pennsylvania Department of Aging. Once such a report is filed, we may be required to provide additional information. ▪  If we believe that a patient presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to carry out the threat or intent, we are required to take protective actions, such as warning the potential victim, contacting the police, or initiating proceedings for hospitalization. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit 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. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information (PHI) about you in your Clinical Record for six (6) years. You may request in writing to examine and/or receive a copy of your Clinical Record, except in unusual circumstances, such as 1) danger to yourself and/or others, 2) where information has been supplied to us confidentially by others, or 3) the record makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to the other person,. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your student clinician, or have them forwarded to another mental health professional so you can discuss the contents. We do not provide copies of testing protocols or test scores directly to patients; however we will provide them to another professional if requested. In most circumstances, we are allowed to charge a fee to cover any expenses incurred providing this information. If we refuse your request for access to your records, you have a right of review (except for information that has been supplied to us confidentially by others). PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment/evaluation records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, we may request an agreement from parents that they consent to give up access to their child’s records. If they agree, during treatment we will provide parents with only general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. RESEARCH WCU CMHS also serves as a site for clinical research conducted by doctoral students and faculty. Patients may be approached for participation in research studies that have received prior approval from the West Xxxxxxx University Institutional Review Board. Prior to any research participation, a separate informed consent fully explaining the study must be provided, and you can choose either to participate or not to participate. You will never be penalized for choosing not to participate in research (i.e., services to which you are ordinarily entitled will not be withheld if you choose not to participate in any research study).

Limits to Confidentiality. The law protects the privacy of all communications between a patient and a mental health providerpsychologist. In most situations, we can only release information about your treatment or assessment to others if you sign a written Authorization. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows: • Clinical information about your case may be shared fully within the WCU CMHS clinic by the students enrolled in clinic practicum and staff/faculty for educational, evaluation educational and therapeutic purposes. If clinical staff present case information at professional conferences, the information will be disguised such that it is impossible to link the information to you or your family. • We employ administrative staff who have access to some of your protected information for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of WCU CMHSthe clinic. • On occasion, WCU CMHS the clinic may find it helpful to consult with another health or mental health professional. During such a consultation, every effort is made to avoid revealing the identity of the patientclient. The other professional is legally bound to keep the information confidential. All consultations are noted in the patient client record. • If a patient client seriously threatens to harm him/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 your consent or authorizationAuthorization: • If you are involved in a court proceeding and a request is made for information concerning the professional services we provided to you, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. • If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. • If a patient client files a complaint or lawsuit against WCU CMHSthe clinic, we may disclose relevant information regarding that patient client as part of our defense. • If we are treating a patient client who files a worker’s compensation claim, we may, upon appropriate request, be required to provide otherwise confidential information to the employer. There are some situations in which we are legally obligated to take actions to protect others from harm and which may require us to reveal some information about a your evaluation/treatment: ▪ If we have reason to believe that a child is the victim of abuse or neglect, the law requires that we file a report with the Pennsylvania Department of Child Welfare (i.e. ChildLine). Once such a report is filed, we may be required to provide additional information. ▪ If we have reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we are required to report this to the Pennsylvania Department of Aging. Once such a report is filed, we may be required to provide additional information. ▪ If we believe that a patient client presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to carry out the threat or intent, we are required to take protective actions, such as warning the potential victim, contacting the police, or initiating proceedings for hospitalization. hospitalization If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit 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. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information (PHI) about you in your Clinical Record for six (6) years. You may request in writing to examine and/or receive a copy of your Clinical Record, except Except in unusual circumstances, such as 1) circumstances that involve danger to yourself and/or others, 2) others or where information has been supplied to us confidentially by others, or 3) the record makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to the such other person,, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your student cliniciantherapist, or have them forwarded to another mental health professional so you can discuss the contents. We do not provide copies of testing protocols or test scores directly to patients; however we will provide them to another professional if requested. In most circumstances, we are allowed to charge a fee to cover any expenses incurred providing this information. If we refuse your request for access to your records, you have a right of review (except for information that has been supplied to us confidentially by others), which your therapist will discuss with you upon request. PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment/evaluation treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, we may request an agreement from parents that they consent to give up access to their child’s records. If they agree, during treatment we will provide parents them with only general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. RESEARCH WCU CMHS also serves as a site for clinical research conducted by doctoral students and faculty. Patients may be approached for participation in research studies that have received prior approval from the West Xxxxxxx University Institutional Review Board. Prior to any research participation, a separate informed consent fully explaining the study must be provided, and you can choose either to participate or not to participate. You will never be penalized for choosing not to participate in research (i.e., services to which you are ordinarily entitled will not be withheld if you choose not to participate in any research study).

Limits to Confidentiality. The law protects the privacy of all communications between a patient and a mental health provider. In most situations, we can only release information about your treatment or assessment to others if you sign a written Authorization. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows: • Clinical information about your case where the clinic may be shared fully within WCU CMHS by the students enrolled in clinic practicum and staff/faculty for educational, evaluation and therapeutic purposes. If clinical staff present case information at professional conferences, the information will be disguised such that it is impossible to link the information to you required or your family. • We employ administrative staff who have access to some of your protected information for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of WCU CMHS. • On occasion, WCU CMHS may find it helpful to consult with another health or mental health professional. During such a consultation, every effort is made to avoid revealing the identity of the patient. The other professional is legally bound to keep the information confidential. All consultations are noted in the patient record. • If a patient seriously threatens to harm him/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 your consent or authorization. These include: • If you are involved in a court proceeding and a request is made for information concerning the professional services we provided to youclinic has knowledge, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your written authorizationevidence, or reasonable concern regarding the abuse or neglect of a court order. If you are involved in child, elderly person, or contemplating litigationdisabled person, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. • If a government agency it is requesting the information for health oversight activities, we may be required to provide it for them. • If a patient files a complaint or lawsuit against WCU CMHS, we may disclose relevant information regarding that patient as part of our defense. • If we are treating a patient who files a worker’s compensation claim, we may, upon appropriate request, be required to provide otherwise confidential information to the employer. There are some situations in which we are legally obligated to take actions to protect others from harm and which may require us to reveal some information about your evaluation/treatment: ▪ If we have reason to believe that a child is the victim of abuse or neglect, the law requires that we file a report with the Pennsylvania Department of Child Welfare (i.e. ChildLine)appropriate agency. Once such a report is filed, we may be required to provide additional information. ▪ If we have reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we are required to report this to the Pennsylvania Department of Aging. Once such a report is filed, we may be required to provide additional information. ▪ If we believe that a patient presents a specific and immediate communicates an explicit threat of serious bodily injury regarding physical harm to a specifically identified or a reasonably clearly identifiable victim or victims, and he/she is likely has the apparent intent and ability to carry out such a threat, the threat or intent, we are clinic may be required to take protective actions, such as warning . These actions may include notifying the potential victim, contacting the police, or initiating proceedings and/or seeking hospitalization for hospitalizationthe patient. If such we believe that there is an imminent or even, in our judgment, high risk that a situation arisespatient will physically harm himself or herself, we will also take protective actions (see Care During Crisis Situations). Although courts have recognized a therapist-patient privilege, there may be circumstances in which a court would order the clinic to disclose personal health or treatment information. We also may be required to provide information about court ordered evaluations or treatments. If you are involved in, or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order the clinic to disclose information. The clinic is required to provide information requested by a legal guardian of a minor child, including a non-custodial parent. If a government agency is requesting information for health oversight activities or to prevent terrorism (Patriot Act), the clinic may be required to provide it. If a patient files a worker’s compensation case, the clinic may be required, upon appropriate request, to provide all clinical information relevant to or bearing upon the injury for which the claim was filed. If a patient files a complaint or lawsuit against the clinic or professional staff, the clinic may disclose relevant information regarding the patient in order to defend itself. If any of these situations were to arise, the clinic would make every effort to fully discuss it with you before taking any action action, and we will would limit 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 discuss any questions or concerns that you may have with us now or in the future. The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information (PHI) about you in your Clinical Record for six (6) years. You may request in writing to examine and/or receive a copy of your Clinical Record, except in unusual circumstances, such as 1) danger to yourself and/or others, 2) where information has been supplied to us confidentially by others, or 3) the record makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to the other person,. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your student clinician, or have them forwarded to another mental health professional so you can discuss the contents. We do not provide copies of testing protocols or test scores directly to patients; however we will provide them to another professional if requested. In most circumstances, we are allowed to charge a fee to cover any expenses incurred providing this information. If we refuse your request for access to your records, you have a right of review (except for information that has been supplied to us confidentially by others). PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment/evaluation records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, we may request an agreement from parents that they consent to give up access to their child’s records. If they agree, during treatment we will provide parents with only general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. RESEARCH WCU CMHS also serves as a site for clinical research conducted by doctoral students and faculty. Patients may be approached for participation in research studies that have received prior approval from the West Xxxxxxx University Institutional Review Board. Prior to any research participation, a separate informed consent fully explaining the study must be provided, and you can choose either to participate or not to participate. You will never be penalized for choosing not to participate in research (i.e., services to which you are ordinarily entitled will not be withheld if you choose not to participate in any research study).___________ Patient Initials

Limits to Confidentiality. The law protects the privacy of all communications between a patient patient/client and a psychologist or other mental health providerprofessional. In most situations, we can only release information about your treatment or assessment to others if you sign a written Authorization. There are other situations Authorization form that require only that meets certain legal requirements imposed by HIPAA and Maine law, or in some cases, if you provide writtenoral authorization. However, advance consentin the following situations, no authorization is required:  You should be aware that this is a group practice with other mental health professionals and administrative staff. Your signature on this agreement provides consent Some staff may see some information for those activitiesthe purposes of scheduling, as follows: • Clinical information about your case may be shared fully within WCU CMHS by the students enrolled in clinic practicum billing, quality assurance, or archival research. In our group practice, there is one electronic chart per patient and staff/faculty for educational, evaluation and therapeutic purposes. If clinical staff present case information at professional conferences, the information any psychologist or clinician who treats that patient will be disguised such that it is impossible to link the information to you or your family. • We employ administrative staff who have access to some of your protected information for both clinical and administrative purposes, such as scheduling, billing and quality assurancethat chart. All staff members have been given training about confidentiality and protecting your privacy and have agreed not to release any information outside of WCU CMHSprivacy. • On occasion, WCU CMHS  Your psychologist or clinician may occasionally find it helpful to consult with another other health or and mental health professionalprofessionals about your treatment. During such a consultationConsultations are usually done in de-identified format – i.e., every effort is made to avoid revealing the identity of the patientwithout mentioning your name. The other professional is professionals are also legally bound to keep the information confidential. All If you don’t object, we will not tell you about these consultations are noted unless we feel it is important to our work together.  Health Psych Maine has contracts with a computer service professional and an accounting firm. As required by HIPAA, we have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the patient recordcontract or otherwise required by law. • If a patient seriously threatens to harm him/herselfyou wish, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protectionyou with the names of these organizations and/or a blank copy of this contract. There are some situations where we are permitted or required to disclose information without your consent or authorization: •  If you are involved in a court proceeding and a request is made for information concerning the professional services we provided to youyour diagnosis and treatment, such information is protected by the psychologist-patient privilege law. 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 us to disclose information. •  If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. •  If a patient files a complaint or lawsuit against WCU CMHSus, we may disclose relevant information regarding that patient as part of our defensein order to defend ourselves. •  If we are treating a patient who files you have filed a worker’s compensation claim, and we mayare being compensated for your treatment by your employer or its insurance company as a result of that claim, we must provide, upon appropriate request, be legally required reports and other information related to provide otherwise confidential information your condition.  If you are pursuing medical or mental health disability payments, you may end up signing a document with that agency or company waiving confidentiality to the employeryour records. In that situation, once you have provided such a waiver or authorization to that other agency or entity, we will then honor their request for your records without further consent from you. There are some situations in which we are legally obligated to take actions in order to protect you or others from harm and which we may require us have to reveal some information about your evaluation/a patient’s treatment: ▪ . These situations are unusual in our practice.  If we know or have reason reasonable cause to believe suspect that a child under 18 has been or is the victim of abuse likely to be abused or neglectneglected or that a vulnerable adult has been abused, neglected, or exploited and is incapacitated or dependent, the law requires that we file a report with the Pennsylvania appropriate government agency, usually the Maine Department of Child Welfare (i.e. ChildLine)Health and Human Services. Once such a report is filed, we may be required to provide additional information. ▪  If we have reason to believe determine that an elderly person or other adult is in need the patient poses a direct threat of protective services (regarding abuse, neglect, exploitation or abandonment), we are required to report this imminent harm to the Pennsylvania Department health or safety of Aging. Once such a report is filedany individual, including himself/herself, we may be required to provide additional information. ▪ If we believe that a patient presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to carry out the threat or intent, we are required disclose information in order to take protective actions, such as warning action(s). These actions may include notifying the potential victim, contacting the police, seeking hospitalization for the patient, or initiating proceedings contacting family members or others who can assist in providing protection.  [As per the HIPAA “Final Rule” effective 9/23/2013] When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the HIPAA Privacy Rule and the state’s confidentiality law. This includes certain narrowly-defined disclosures as described above or to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for hospitalizationpublic health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit 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 complexcomplex and we are not attorneys. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information (PHI) about you in your Clinical Record for six (6) years. You may request in writing to examine and/or receive a copy of your Clinical Record, except in unusual circumstances, such as 1) danger to yourself and/or others, 2) where information has been supplied to us confidentially by others, or 3) the record makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to the other person,. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your student clinician, or have them forwarded to another mental health professional so you can discuss the contents. We do not provide copies of testing protocols or test scores directly to patients; however we will provide them to another professional if requested. In most circumstances, we are allowed to charge a fee to cover any expenses incurred providing this information. If we refuse your request for access to your records, you have a right of review (except for information that has been supplied to us confidentially by others). PATIENT RIGHTS HIPAA provides you with several rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment/evaluation records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, we may request an agreement from parents that they consent to give up access to their child’s records. If they agree, during treatment we will provide parents with only general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. RESEARCH WCU CMHS also serves as a site for clinical research conducted by doctoral students and faculty. Patients may be approached for participation in research studies that have received prior approval from the West Xxxxxxx University Institutional Review Board. Prior to any research participation, a separate informed consent fully explaining the study must be provided, and you can choose either to participate or not to participate. You will never be penalized for choosing not to participate in research (i.e., services to which you are ordinarily entitled will not be withheld if you choose not to participate in any research study).