This section contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purposed of treatment, payment and health care operations.
It is very important that you read these documents carefully. We can discuss any questions you have about the procedures. When you sign the signature page of the intake form, your signature will represent an agreement between us. You may revoke this agreement in writing at any time. The revocation will be binding on me unless I have taken action in reliance on it, if you have not satisfied any financial obligations that you have incurred.
The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA.
SOME SITUATIONS REQUIRE ONLY THAT YOU PROVIDE WRITTEN, ADVANCE CONSENT. YOUR SIGNATURE ON THIS AGREEMENT PROVIDES CONSENT FOR THOSE ACTIVITIES, AS FOLLOWS:
I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your clinical record (PHI).
I employ no administrative staff. The lobby receptionists have no access to any information concerning you and, to that point, they are never provided with your name unless and until you choose to tell them your name. You never have to provide your name when you enter the building, as this is part of the confidentiality to which you are entitled.
I employ no accountant, answering service, or transcriptionists.
I do not participate on any insurance panels.
If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.
THERE ARE SOME SITUATIONS WHERE I AM PERMITTED OR REQUIRED TO DISCLOSE INFORMATION WITHOUT EITHER YOUR CONSENT OR AUTHORIZATION:
If you are involved in a court proceeding and a request is made for information concerning my professional services, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court order would be likely to order me to disclose information.
If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.
If a client files a worker's compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, furnish copies of all medical/psychological reports and bills.
There are some situations in which I am legally obligated to take actions which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client's treatment. These situations are highly unusual in my practice.
If I have reason to believe that a child has been abused, the law requires that I file a report with the appropriate governmental agency, usually the Department of Family and Children's Services or the Department of Human Resources. Once such a request is filed, I may be required to provide additional information.
If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the Department of Human Resources. Once such a report is filed, I may be required to provide additional information.
If I determine that a client presents a serious danger of violence to another, I may be required to take protective action. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the client.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.