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Terms and Policy

Acknowledgement Form

Acknowledgement Form >

COMMITMENT TO COUNSELING: A necessary element of the counseling process is your commitment to attend sessions regularly. You may stop the counseling at any time, but please inform me before your last session. Attending sessions under the influence of alcohol or drugs or in possession of a weapon is not allowed. Your signature below indicates that you have read, understand, & agree to the information in this document. 

Receipt of Notice of Policy and Practices to Protect the Privacy of your Health Information 

I acknowledge that I have been given a copy of 'Notice of Privacy Practices'

                                    HIPAA Notice of Policies and Practices to Protect the Privacy of Your Health Information

Please review it carefully. 

1. Uses and Disclosures for Treatment, payment, and Health Care Operations 
We may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:  - "PHI" refers to information in your health record that could identify you.  - "Treatment, Payment, and Health Care Operations" 
-Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist.  - Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.  - Health Care Operations are activities that relate to the performance and operation of my practice. Examples of healthcare operations are quality assessment and improvement activities, business related matters such as audits and administrative services, and case management and care coordination.  - "Use" applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.  - "Disclosure" applies to activities outside of my office such as releasing, transferring, or providing access to information about you to other parties. 
2. Uses and Disclosures Requiring Authorization  We may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment, and healthcare operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.  You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under policy. 

3. Uses and Disclosures with Neither Consent nor Authorization  We may use or disclose PHI without your consent or authorization in the following circumstances:  - Child Abuse: If we have cause to believe that a child has been, or may be, abused, neglected, or sexually abused, we must make a report of such within 48 hours to the Texas Department of Protective and Regulatory Services, the Texas Youth commission, or to any local or state law enforcement agency.  - Adult and Domestic Abuse: If we have cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, we must immediately report such to the Department of Protective and Regulatory Services.  - Health Oversight: If a complaint is filed against me with the State Board of Licensed Professional Counselors, the Board has the authority to subpoena confidential mental health information from us relevant to the complaint.  - Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and we will not release information, without written authorization from you or your personal or legally appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.  - Serious Threat to Health or Safety: If it is determined that there is a probability of imminent physical injury by yourself or others, or there is a probability of immediate mental or emotional injury to you, we may disclose relevant confidential mental health information to your emergency contact or medical or law enforcement personnel.  - Worker's compensation: If you file a worker's compensation claim, we may disclose records relating to your diagnosis and treatment to your employer's insurance carrier.

4. Patients' Rights and Counselor's Duties:  - Right to Request Restrictions- You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.  - Right to Receive Confidential communications by Alternative means and at Alternative locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family  member to know that you are being seen at this office. Upon your request, I will send your bills to another address.)  - Right to Inspect and Copy-You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. 
Your access to PHI may be denied under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.  - Right to Amend- You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.  - Right to Accounting- You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section 2 of this notice.) On your request, I will discuss with you the details of the accounting process.  - Right to a Paper Copy- You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.  Counselor's Duties:  - I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI  - I reserve the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, I am required to abide by the terms currently in effect.  - If I revise my policies, I will notify you of such revisions. 
5. Complaints: If you are concerned that your privacy rights have been violated, or you disagree with a decision made about access to your records, you may contact me at my phone number listed above. You may also send a written complaint to the Secretary of the US Department of Health and Human Services.

6. Effective Date, Restrictions and Changes to Privacy Policy 
You will be provided an "Acknowledgement Form" in which you may acknowledge receipt of this form.

( Type Full Name )
( Full Name )
Cancellation Policy

Cancellation of Appointments

Please keep in mind that your appointment time is reserved for you and only you. If you will not be able to attend your appointment, please call and cancel your appointment no less than 48 hours prior to your appointment. 

A client who cancels an appointment with less than forty-eight hours prior to an appointment or who does not attend a scheduled appointment will be charged the regular fee for that appointment. Please note that EAP and insurance plans will not pay for this fee.  My signature below indicates that I understand, acknowledge, and accept the policies above.

( Type Full Name )
( Full Name )