THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

September 1, 2009

The law protects the privacy of communications between a client and a counselor. 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 (Health Insurance Portability and Accountability Act of 1996). There are other situations that require only that you provide written advanced consent. Your signature on the Informed Consent Agreement provides consent for those activities as follows.

Use and disclosure of protected health information for the purposes of providing services: Providing treatment services, collecting payment, and conducting healthcare operations are necessary activities for quality care. State and federal laws allow me to use and disclose your health information for these purposes as follows.

TREATMENT: I may use and disclose health information to:

1. Provide, manage, or coordinate care with your physician or other healthcare provider who is also treating you.

2. Ensure that I am providing the highest quality counseling, I may consult with other mental health providers. During such consultations, I make every effort to avoid revealing the identity of my client. The other professionals are legally bound to keep the information confidential. I will note all consultations in your records.

COLLECTING PAYMENT: If you are using your insurance for payment, it is necessary to disclose clinical information in order to get an authorization for counseling sessions. If you would like to pay out of pocket and attempt to seek reimbursement for counseling from your health insurance provider, I will disclose information to your insurance provider at your request. If you have not paid for services at the time of your appointment as required, I may be forced to send you a bill which may include information that identifies the client as well as other healthcare information.

HEALTHCARE OPERATIONS: I may have to disclose health information for both clinical and administrative purposes, such as review of treatment procedures, review of business activities, certification, compliance, and licensing activities.

OTHER USES AND DISCLOSURES WITHOUT YOUR CONSENT:

1. I am mandated to report the following to the appropriate authorities:

a. 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 Human Resources. Once such a report is filed, I may be required to provide additional information;

b. if I have reason to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon them, 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;

c. if I determine that a client represents a serious danger of violence to another, I may be required to take protective actions. 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;

d. if I determine that you are a serious threat to yourself, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide protection;

e. if ordered by a court of law. If you are involved in a court proceeding and a request is made for information regarding my professional services, such information is protected by the counselor-client privilege law, unless I am ordered to release it by the court. If you are involved in or contemplating

litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information;

f. if a government agency is requesting information for health oversight activities, I may be required to provide it for them;

g. if a client files a complaint or lawsuit against me, I may disclose relevant information regarding the client in order to defend myself;

h. if a client files a workers’ compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, furnish copies of all medical reports and bills.

Fortunately, these situations are unusual in my practice.

CLIENTS’ RIGHTS

1. You have the right to request where I contact you: home, work, cell phone, e mail, or some other means of your choice.

2. You have the right, by written authorization, to release your medical records to others. You also have the right to revoke that release in writing. Revocation is not valid to the extent that I have already acted in reliance on your previous authorization.

3. You have the right to make a written request to inspect and copy your records. You will be charged $0.10 per page for copying in addition to any mailing costs. Certain information in your record may be removed prior to your receipt if I feel it may cause harm to you.

4. You have the right to make a written request that I amend your records. I will have at least 30 days to decide whether to amend your records as you have requested and in some instances may deny your request. If your request is denied, you have the right to file a disagreement statement. Your disagreement statement and my response will be filed in the record.

5. You have the right to make a written request for an accounting of disclosures made of your health information with the following exceptions: disclosure for treatment, payment, or healthcare operations; disclosures pursuant to a signed release; disclosures made to the client; disclosures for national security or law enforcement purposes.

6. You have the right to make a written request to restrict uses and disclosures of your healthcare information; however, I am not obligated to agree to your request. If I do not agree to your request, you have the right to complain: first to me and secondly to the U.S. Department of Health and Human Services. I will not retaliate against you for such complaints.

7. You have the right to receive changes in policies.

If you have any questions or concerns about the foregoing, please do not hesitate to ask me, and I will make every attempt to answer them.