Please read this notice carefully.
Keep this for your records.
I am required by applicable federal and state law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices, legal obligations, and your rights concerning your health information (“Protected Health Information” or “PHI”). I must follow the privacy practices that are described in this Notice (which may be amended from time to time). For more information about my privacy practices, or for additional copies of this Notice, please contact me using the information listed in Section II G of this notice.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
- Permissible Uses and Disclosures without Your Written Authorization. I may use and disclose PHI without your written authorization, excluding Psychotherapy Notes as described in Section II, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law. Treatment: I may use and disclose PHI in order to provide treatment to you. For example, I may use PHI to diagnose and provide counseling service to you. In addition, I may disclose PHI to other health care providers involved in your treatment.
- Payment: I may use or disclose PHI so that services you receive are appropriately billed to, and payment is collected from, your health plan. By way of example, I may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.
- Health Care Operations: I may use and disclose PHI in connection with our health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities.
- Required or Permitted by Law: I may use or disclose PHI when I am required or permitted to do so by law. For example, I may disclose PHI to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. In addition, I may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions or otherwise as authorized by law.
- Clinical Supervision: I am a Licensed Mental Health Counselor Associate, which means I am working on gaining the necessary clinical experience for full licensure. Until I am fully licensed, I am required to have clinical supervision. My Supervisor is Joe Klemz, LICSW (360-619-2226; email@example.com). I may discuss your assessment, treatment planning, and treatment progress with my supervisor in order to improve your quality of care.
- Uses and Disclosures Requiring Your Written Authorization
- Psychotherapy Notes: Notes recorded by your clinician documenting the contents of a counseling session with you (“Psychotherapy Notes”) will be used only by your clinician and will not otherwise be used or disclosed without your written authorization.
- Marketing Communications: I will not use your health information for marketing communications without your written authorization.
- Other Uses and Disclosures: Uses and disclosures other than those described in Section I.A. above will only be made with your written authorization. For example, you will need to sign an authorization form before I can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.
YOUR INDIVIDUAL RIGHTS
- Right to 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. Under limited circumstances, I may deny access to your records. I may charge a fee for the costs of 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. (e.g., records related to mental health, drug treatment, or family planning services)].
- Right to Alternative Communications. You may request, and I will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.
- Right to Request Restrictions. You have the right to request a restriction on PHI used for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to the Privacy Officer as indicated below. I am not required to agree to any such restriction you may request.
- Right to 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, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations.
- Right to Request Amendment: You have the right to request that I amend your health information. Your request must be in writing, and it must explain why the information should be amended. I may deny your request under certain circumstances.
- Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to the Privacy Officer at any time.
- Questions and Complaints. If you desire further information about your privacy rights, or are concerned that I have violated your privacy rights, you may file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. I will not retaliate against you if you file a complaint with the Director or myself.
EFFECTIVE DATE AND CHANGES TO THIS NOTICE
- Effective Date. This Notice is effective on June 1, 2016
- Changes to this Notice. I may change the terms of this Notice at any time. If I change this Notice, I may make the new notice terms effective for all PHI that I maintain, including any information created or received prior to issuing the new notice. If I change this Notice, I will post the revised notice in the waiting area of my office. You may also obtain any revised notice by contacting the Privacy Officer.
This information regarding the counseling relationship has been provided for your protection and assistance in making an informed choice about treatment.
When clients share personal information and the counselor responds with respect and authenticity, sessions may seem emotionally intimate. To maintain a safe and beneficial environment the counseling relationship will remain professional, it will not become personal. Contact will be limited to the sessions in the office over the phone, or other secure communications methods agreed upon with the client, all communication will focus on client concerns. For the benefit of the client, the client and counselor will not engage in physical contact, socialize, give gifts to each other, nor establish any relationship other than the professional counseling relationship. Cultural sensitivity may require some modification, any modification will be noted in the clinical record and disclosed to the supervisor.
Everything said in therapy is confidential and will not be disclosed except when, based upon information gained from the client or a third party, the therapist is required or permitted by the HIPAA Privacy Standard or Washington state law, including the following:
- Reporting of suspected abuse or neglect of a child, developmentally disabled person, or a dependent adult;
- Action to protect from potential suicidal behavior;
- Warning to encourage safety when there is threatened harm to another, which may include knowledge that the client has a communicable and life-threatening disease when there is an unwillingness to inform individuals with whom the client is intimately involved; and
- When required by compulsory process.
- When a client signs a written authorization or in the event that a complaint is filed by the client against the counselor;
- Payment by check permits bank employees to view names of clients;
- Electronic communication by phone, cell phone, email, FAX, or internet, increases the risk of breach of confidentiality with electronic transmission and caller identification;
- If insurance reimbursement is sought, confidentiality is waived;
In keeping with generally accepted standards of practice, periodic supervision and consultation is made regarding the management of cases with other health professionals, who are bound by the rules of confidentiality as stated herein.
Rights of Clients
Therapy is understood to be a choice made by the client. Outcomes cannot be guaranteed. Clients who choose therapy may benefit from treatment and experience improvement in symptoms, or they could fail to improve, or even potentially worsen. The client may choose not to seek treatment at this time. Alternative options include other counselors, books, support groups, self-help resources, and other modes of treatment. Medical treatment may also be an option. If therapy is chosen, some clients need only a few sessions to achieve their goals, while others may require months or even years of counseling. The client has the right to stop receiving services at any time, however, it is understood that stopping services prematurely may result in the return or worsening of initial problems and symptoms.
It is appropriate for clients to raise questions about the counselor’s orientation and training, diagnoses, fee policies, and course of treatment. Communication between client and counselor is considered to be part of the clinical record, which is accessible to the client upon written request to view or to obtain copies. Records are maintained for a period of ten years from date of the last session. Records of minor clients will be retained for a period of ten years after their 18th birthday or ten years from the date of the last session, whichever is the later.
Clients are encouraged to talk with the counselor directly if dissatisfied with services received, desirous of a second opinion or referral, or if intending to discontinue appointments. If the counselor is not able to resolve the client’s concerns, a complaint can be filed with:
The Department of Health; Customer Service Center
Address: 310 Israel Road S.E.
Tumwater, WA. 98501
Phone: (360) 236-4700; Fax: (360) 236-4818
Web Site: WWW.DOH.WA.GOV/HSQA
The Uniform Disciplinary Act provides standardized procedures for the licensure of health care professionals and the enforcement of laws to assure the public of the adequacy of professional competence and conduct in the healing arts. Acts of unprofessional conduct are listed under RCW 18.130.180, a copy of which may be obtained from the Department of Health at the above address.
If in need of emergency services, the client should call a crisis line at (800) 273-8255, (360)696-9560, (800)626-8137, (503)988-4888, or call 911.