Common use of PROFESSIONAL RECORDS Clause in Contracts

PROFESSIONAL RECORDS. The laws and standards of our profession require that we keep Protected Health Information about you in your Clinical Record. We retain the records of individuals seen before their 18th birthday for 7 years after their 18th birthday. Individuals who are seen when they are 18 years old or older are retained for 7 years. Please contact Twin State Psychological Services at (000) 000-0000 if you have any questions about this Record Retention Policy. 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 these reasons, we recommend that you initially review them in our presence, or have them forwarded to another mental health professional so you can discuss the contents. (We are sometimes willing to conduct this review meeting without charge.) In most circumstances, we charge a copying fee of $0.25 per page (and for certain other related expenses). HIPAA provides you with several rights with regard to your Clinical Record and disclosures of protected 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 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.

PROFESSIONAL RECORDS. The laws and standards of our my profession require that we keep Protected Health Information about you your or your child in your your/their Clinical Record. We retain the records of individuals seen before their 18th birthday for 7 years after their 18th birthday. Individuals who are seen when they are 18 years old or older are retained for 7 years. Please contact Twin State Psychological Services at (000) 000-0000 if If you provide us with an appropriate written request, you have any questions about this Record Retention Policy. You may the right to examine and/or receive a copy of your Clinical Record, if you request it in writing(child’s) records. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For these reasonsthis reason, we recommend that you initially review them in our presence, or have them forwarded to another mental health professional so you can discuss the contents. (We are sometimes willing to conduct this review meeting without charge.) . In most circumstancessituations, we are allowed to charge a copying fee of $0.25 1.00 per page (and for certain other related expenses). Except in rare circumstances, you may examine and/or receive a copy of your entire record, if you request it in writing. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected 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 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. Since this is a pediatric practice, it is important for patients under 18 years of age who are not emancipated and their parents to be aware that the law allows parents to examine their child’s treatment records unless we decide that such access is likely to injure the child or we agree otherwise.

PROFESSIONAL RECORDS. The laws and standards of our my profession require that we keep Protected Health Information protected health information (PHI) about you in your Clinical Recordmedical record. We retain the records of individuals seen before their 18th birthday for 7 years after their 18th birthday. Individuals who are seen when they are 18 years old or older are retained for 7 years. Please contact Twin State Psychological Services at (000) 000-0000 if Except in unusual circumstances that involve danger to yourself and/or others, you have any questions about this Record Retention Policy. You may examine and/or receive a copy of your Clinical Record, clinical record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readersconfusing if read without the guidance of a mental health professional. For these reasonsthis reason, we recommend that you initially review them in our presence, or have them forwarded to another mental health professional so you can discuss the contents. (We are sometimes willing to conduct this review meeting without charge.) In most circumstances, we are allowed to charge a copying fee of $0.25 per page (25.00 or more. If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon your request. Insurance companies can request and for certain other related expenses)receive a copy of your clinical record. Patient Rights: HIPAA provides you with several rights with regard to your Clinical Record clinical record and disclosures of protected health informationPHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our my policies and procedures recorded in your records; , and the right to request a paper copy of this Agreement. Emergency/After hours Service: If you are in need of emergency services, call 911 or proceed to the attached Notice formnearest hospital emergency room. If you have an urgent after hours issue which cannot wait until the next business day, you may call the office number (000) 000-0000 and our privacy policies follow the recorded message instructions for how to contact the on-call physician. This option is reserved for urgent issues and proceduresdoes not apply to refill requests or scheduling issues. We are happy *If the patient is a minor, he/she will not be seen without his/her legal guardian present. Forms and Letter: Any additional paperwork, letters, or forms not specifically related to discuss any intra-office care, will be subject to a fee based on the time it takes to complete the documentation ($10 for 10-15 min, $25 for 20-30 min, $50 for 45-60 min, etc.) which will need to be paid prior to release of these rights with youthe paperwork.

PROFESSIONAL RECORDS. The laws and standards of our the profession require that we keep Protected Health Information (PHI) is kept about you in your Clinical Record. We retain This PHI includes information about your reasons for seeking services, a description of the ways in which your problem impacts your life, your diagnosis, the goals we set for treatment, your progress toward your goals, your medical and social history, your treatment history, and past treatment records received from providers, reports of individuals seen before their 18th birthday for 7 years after their 18th birthdayany professional consultations, your billing records, and any reports that have been sent to anyone. Individuals who are seen when they are 18 years old Your information is kept in a secure electronic health record (EHR 24/7) or older are retained for 7 years. Please contact Twin State Psychological Services at (000) 000-0000 if you have any questions about this Record Retention Policyin a secure paper chart. You or your legal representative 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 these reasonsthis reason, we recommend it is recommended that you initially review them in our presence, the presence of your provider or have them forwarded to another mental health professional so you can discuss the contents. In unusual circumstances involving potential danger to you or others or if it is believed that access to your record is reasonably likely to cause substantial harm to you, your request may be denied. If I refuse your request for access to your records, you have a right of review through a private attorney (We are sometimes willing except for information provided to conduct this review meeting without charge.) your provider confidentially by others), which will be discussed with you upon request. In most circumstancessituations, we Bayer NeuroBehavioral Center is allowed to charge a copying fee of $0.25 1.00 per page (and for certain other related expenses)page. HIPAA provides you with several specific rights with regard to your Clinical Record and disclosures of protected health PHI. You have been provided with a copy of that document (Notice of Privacy Practices- pages 5-6) and have discussed those issues. Please remember that you may reopen the conversation with your provider at any time. Patients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s treatment records unless your provider believes that doing so would endanger the child or an alternate agreement is made. Because privacy in psychological services is often crucial to successful progress, particularly with teenagers, it is our policy (at times) to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, general information will be provided about the progress of the child’s treatment, and his/her attendance at scheduled sessions. A summary of the child’s treatment will be provided when treatment is complete. Any other communication will require the child’s Authorization, unless your provider feels that the child is in danger or is a danger to someone else, in which case, the parents will be notified of the concern. Before giving parents any information, your provider will discuss the matter with the child, if possible, and do their best to handle any objections he/she may have. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed • You have read this Psychologist-Patient Services Agreement. • You agree to others; requesting an accounting of most disclosures of protected health information its terms. • You acknowledge that you have neither consented read the HIPAA Notice Form for FL described above (pg 5-6). • You agree BNBC can provide and obtain requested information to nor authorized; determining and from a third party payer. Please check the location boxes below if you would like 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 receive 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 youthe following documents. q Psychologist-Patient Services Agreement (this document) q HIPAA Notice Form for Florida q Patient Request for Accounting for Disclosures of Health Information q Request for Confidential Handling of Health Information q Release of Information Form Signature / Date Signature of Parent or Legal Guardian / Date Printed Name Printed Name of Parent or Legal Guardian Rev. March 2020 Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

PROFESSIONAL RECORDS. The laws and standards of our my profession require that we I keep Protected Health Information about you in your Clinical Record. We retain It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of individuals seen before their 18th birthday for 7 years after their 18th birthday. Individuals who are seen when they are 18 years old or older are retained for 7 years. Please contact Twin State Psychological Services at (000) 000-0000 if you any professional consultations, your billing records, and any reports that have any questions about this Record Retention Policybeen sent to anyone, including reports to your insurance carrier. 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 these reasonsthis reason, we recommend that you initially review them in our presence, or have them forwarded to another mental health professional so you can discuss the contents. (We are sometimes willing to conduct this review meeting without charge.) In most circumstances, we are allowed to charge a copying fee of $0.25 5 per page (and for certain other related expenses). HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of 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 my privacy policies and procedures. We are I am happy to discuss any of these rights with you.

PROFESSIONAL RECORDS. The laws and standards of our profession require that we keep Protected Health Information about you in your Clinical Record. We retain the records of individuals seen before their 18th birthday for 7 years after their 18th birthday. Individuals who are seen when they are 18 years old or older are retained for 7 years. Please contact If Twin State Psychological Services stops providing services, i.e., closes our office, your records will be retain as stated. The Medical Staff Office at (000) 000-0000 Springfield Hospital will be able to provide our contact information for you if you have any questions about this Record Retention Policyare unable to contact our office via telephone. You may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For these reasons, we recommend that you initially review them in our presence, presence or have them forwarded to another mental health professional so you can discuss the contents. (We are sometimes willing to conduct this review meeting without charge.) In most circumstances, we charge a copying fee of $0.25 per page (and for certain other related expenses). Please contact Twin State Psychological Services at (000) 000-0000 if you have any questions about this Record Retention Policy at any time. HIPAA provides you with several rights with regard to your Clinical Record and disclosures of protected 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 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.