Notice of Privacy Practices
EFFECTIVE DATE: APRIL 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Your health record contains personal information about you and
your health. This information about you that may identify you and
that
relates to your past, present or future physical or mental health
or condition and related health care services is referred to as
Protected Health Information ("PHI"). This Notice of
Privacy Practices describes how I may use and disclose your PHI
in accordance with
applicable Federal and State law. It also describes your rights
regarding how you may gain access to and control your PHI
I am required by law to maintain the privacy of PHI and to provide
you with notice of my legal duties and privacy practices with respect
to PHI. I am required to abide by the terms of this Notice of Privacy
Practices. I reserve the right to change the terms of my Notice
of Privacy Practices at any time. Any new Notice of Privacy Practices
will be effective for all PHI that I maintain at that time. I will
provide you with a copy of the revised Notice of Privacy Practices
by sending a copy to you in the mail upon request or providing
one to you at your next appointment.
A. Treatment:
The information you provide to me will be recorded in your record
and used to decide what care is right for you. I
will request your permission to give to or receive from other health
care providers (for example your physician, or previous counselors)
information that you and I agree is important to be shared, in
order for you to receive the best care. I will receive consultation
from time to time from a consultant or colleagues. If I discuss
your treatment, I will not use any identifying information in order
to protect your confidentiality.
B. Payment: I may use or disclose PHI so that services you receive
are appropriately billed to and payment is received from your health
plan. I will ask your permission to reveal necessary information
for billing purposes.
C. Psychotherapy Notes: Notes I record documenting the contents
of a counseling session with you ("Psychotherapy Notes")
will be used only by me, and will not otherwise be used or disclosed
without your written authorization. However, as explained in my
disclosure statement, in the following situations I could not maintain
the confidentiality of my notes or your PHI;
•
In cases of suspected abuse or neglect
•
If I believed your or another's life was endangered
•
To the extent disclosure is required by law
•
If I was served with a court order requiring me to provide PHI
D. Marketing Communications: I will not use your health information
for marketing communications without your written authorization.
E. Other uses and Disclosures: Uses and disclosure other than
those described above will only be made with your written authorization
You have the following rights with
respect to the information in your medical record, including the
right to:
A. Inspect and Copy. You may request access to your medical record
and billing records maintained by me in order to inspect and request
copies of the records. All requests for access must be made in
writing. I may deny access to your records only in those situations
where there is compelling evidence that access would cause serious
harm to you. I may charge a reasonable cost-based fee for copying
and sending you any records requested. If you are a parent or legal
guardian of a minor, please note that certain portions of the minor's
medical record will not be accessible to you.
B. Request Confidential Communications. You have the right to
request that I communicate with you about anything related to your
treatment in a certain way or at a certain location.
C. Request Restrictions on PHI used for disclosure for treatment,
payment or health care operation. You must request any such restriction
in writing. I am not required to agree to your request.
D. Accounting of Disclosures. Upon written request, you may obtain
an accounting of certain disclosures of PHI made by me after April
14, 2003. This right applies to disclosures for purposes other
than treatment, payment or health care operations, and excludes
disclosures made to you or disclosures otherwise authorized by
you.
E. Request Amendment. If you feel that the PHI I have about you
is incorrect or incomplete, you may ask me to amend the information,
although I am not required to agree to the amendment.
F. Obtain Notice. You may receive a paper copy of this notice
by requesting it from me at any time.
Questions and Complaints. If you wish further information about
your privacy rights, or are concerned that I have violated your
privacy rights, please let me know. You may also file written complaints
with the Director, Office for Civil Rights of the U.S. Department
of Health and Human Services at 200 Independence Avenue, S.W. Washington
D.C. 20201, or by calling (202)619-0257 I will not retaliate against
you if you file a complaint.
My signature below certifies that I
have received and read Susan Goedde's Disclosure Statement , the
State of Washington's brochure "Counseling
or Hypnotherapy Clients" and her Notice of Privacy Practices.
I have had an opportunity to ask any questions I may have about
these statements, the information in the brochure, and working
with Susan, and I understand and agree to the policies stated in
these documents.
(Client signature) _______________________________Date:________
My signature below means that I have provided you with the Disclosure
Statement, with a copy of the Washington State brochure "Counseling
or Hypnotherapy Clients", and with my Notice of Privacy Practices.
(Therapist signature)____________________________Date:_________
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