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This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.
WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to Michael RoBards, LCSW and RoBards Counseling that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Michael RoBards, LCSW and RoBards Counseling. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Michael RoBards, LCSW and RoBards Counseling will use his/her clinical judgment when revealing such information. Michael RoBards, LCSW and RoBards Counseling will not release records to any outside party unless s/he is authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client, unless he/she is required by law. While I will do my best to seek your authorization to release the requested information regarding our psychotherapy from you first, in some situations a judge can order the release of the records of your psychotherapy with me or may order me to testify in regard to our therapeutic work.
EMERGENCY: If there is an emergency during therapy, or in the future after termination, where Michael RoBards, LCSW and RoBards Counseling becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, s/he will do whatever s/he can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, s/he may also contact the person whose name you have provided on the biographical sheet.
HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct Michael RoBards, LCSW and RoBards Counseling, only the minimum necessary information will be communicated to the carrier. Michael RoBards, LCSW and RoBards Counseling has no control over, or knowledge of, what insurance companies do with the information s/he submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and may be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.
LITIGATION: Sometimes patients become involved in litigation while they are in therapy or after therapy has been completed. Sometimes patients (or the opposing attorney, in a legal case) want the records disclosed to the legal system. Due to the nature of the psychotherapeutic process and the fact that it often involves making a full disclosure with regard to many matters, clients’ records are generally confidential and private in nature. Patients should know that very serious consequences can result from disclosing therapy records to the legal system. Such disclosures may negatively affect the outcome of custody disputes or other legal matters and may negatively affect the therapeutic relationship. If you or the opposing attorney are considering requesting Michael RoBards, LCSW and RoBards Counseling’s disclosure of the records, Michael RoBards, LCSW and RoBards Counseling will do his/her best to discuss with you the risks and benefits of doing so. As noted in this document, you have the right to review your own psychotherapy records anytime. (See also relevant section above: "WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW")
CONSULTATION: Michael RoBards, LCSW and RoBards Counseling consults regularly with other professionals regarding his clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.
E–MAILS, CELL PHONES, TEXTS, COMPUTERS, AND FAXES: It is very important to be aware that computers and unencrypted emails, texts, and e-fax communications (which are part of the clinical records) can be rather easily accessed by unauthorized people and, hence, can compromise the privacy and confidentiality of such communications. Emails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all emails, texts and e-faxes that go through them. While data on Michael RoBards, LCSW and RoBards Counseling’s laptop is encrypted, emails, texts and e-faxes are not. It is always a possibility that e-faxes, texts, and emails can be sent erroneously to the wrong address and computers. Michael RoBards, LCSW and RoBards Counseling’s laptop is equipped with a firewall, VPN, a virus protection and a password. Also, be aware that phone messages are transcribed and sent to Michael RoBards, LCSW and RoBards Counseling via unencrypted emails. Please notify Michael RoBards, LCSW and RoBards Counseling if you decide to avoid or limit, in any way, the use of email, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted emails, texts or e-faxes or via phone messages, Michael RoBards, LCSW and RoBards Counseling will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and he will honor your desire to communicate on such matters. Please do not use texts, emails, voice mails, or faxes for emergencies.
RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of Michael RoBards, LCSW and RoBards Counseling profession require that s/he keep treatment records for at least _____ years. Please note that clinically relevant information from emails, texts, and faxes are part of the clinical records. Unless otherwise agreed to be necessary, Michael RoBards, LCSW and RoBards Counseling retains clinical records only as long as is mandated by (insert your state) law. If you have concerns regarding the treatment records, please discuss them with Michael RoBards, LCSW and RoBards Counseling. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when Michael RoBards, LCSW and RoBards Counseling assesses that releasing such information might be harmful in any way. In such a case, Michael RoBards, LCSW and RoBards Counseling will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, Michael RoBards, LCSW and RoBards Counseling will release information to any agency/person you specify unless Michael RoBards, LCSW and RoBards Counseling assesses that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, Michael RoBards, LCSW and RoBards Counseling will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.
TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Michael RoBards, LCSW and RoBards Counseling between sessions, please leave a message at the answering service (502)225-3025 and your call will be returned as soon as possible. Michael RoBards, LCSW and RoBards Counseling checks his/her messages a few times during the daytime only, unless s/he is out of town. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away call 24 crisis line at (In Louisville): 211 or (502) 589-4313 or the Police: 911. Please do not use email or faxes for emergencies. Michael RoBards, LCSW and RoBards Counseling does not always check his/her email or faxes daily.
PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee of $150.00 per 55 minute session at the end of each session unless other arrangements have been made. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify Michael RoBards, LCSW and RoBards Counseling if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, Michael RoBards, LCSW and RoBards Counseling will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement, if you so choose. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, Michael RoBards, LCSW and RoBards Counseling can use legal or other means (courts, collection agencies, etc.) to obtain payment.
THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Michael RoBards, LCSW and RoBards Counseling will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Michael RoBards, LCSW and RoBards Counseling may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Michael RoBards, LCSW and RoBards Counseling is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational. Michael RoBards, LCSW and RoBards Counseling provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within his/her scope of practice.
TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, Michael RoBards, LCSW and RoBards Counseling will discuss with you his/her working understanding of the problem, treatment plan, therapeutic objectives, and his/her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their
possible risks, Michael RoBards, LCSW and RoBards Counseling's expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.
Dual Relationships
Despite a common misconception, not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Michael RoBards, LCSW and RoBards Counseling's objectivity, clinical judgment or therapeutic effectiveness or can be exploitative in nature. Michael RoBards, LCSW and RoBards Counseling will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. It is important to realize that in some communities, particularly small towns, small communities, military bases, university campuses, spiritual and rehabilitation communities, etc., multiple relationships are either unavoidable or expected. Michael RoBards, LCSW and RoBards Counseling will never acknowledge working with anyone without his/her written permission. Many clients have chosen Michael RoBards, LCSW and RoBards Counseling as their therapist because they knew him/her before they entered into therapy with him/her and/or were aware of his/her stance on the topic. Nevertheless, Michael RoBards, LCSW and RoBards Counseling will discuss with you, the often-existing complexities, potential benefits and difficulties that may be involved in such relationships. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to communicate to Michael RoBards, LCSW and RoBards Counseling if the dual relationship becomes uncomfortable for you in any way. Michael RoBards, LCSW and RoBards Counseling will always listen carefully and respond accordingly to your feedback. Michael RoBards, LCSW and RoBards Counseling will discontinue the dual relationship if he finds it interfering with the effectiveness of the therapeutic process or your welfare and of course you can do the same at any time.
Minors in Therapy
If you are under eighteen years of age, please be aware that the law may give your parents or guardians the right to obtain information about your treatment and/or examine your treatment records. It is my policy to request a written agreement from your parents or guardians indicating that they consent to give up access to such information and/or, to your records. If they agree, I will provide them only with general information about our work together subject to your approval, or, if I feel it is important for them to know in order to make sure that you and people around you are safe. If I think it is appropriate, I will involve them if I feel that there is a high risk that you will seriously harm yourself or another/others. Before giving them any verbal or written information, I will discuss the matter with you, if possible. I will do the best I can to resolve any differences that you and I may have about what I am prepared to discuss.
Group Therapy
In group therapy, it is of utmost important that all members maintain confidentiality and neither disclose the content of sessions nor the identity of fellow group members. It is highly recommended that any meaningful exchange outside the group also be discussed in the group. In group therapy, the other members of the group are not therapists. They are not regulated by the same ethics and laws that bind your therapist. The limits of confidentiality and the reporting laws have been outlined earlier in this document. While the expectation is that all group members will maintain confidentiality regarding anything said in the group, you cannot be certain that they will. You are ultimately responsible for what you say and what you think, feel, or do with the feedback you receive in the group.
TERMINATION: As set forth above, after the first couple of meetings, Michael RoBards, LCSW and RoBards Counseling will assess if he can be of benefit to you. Michael RoBards, LCSW and RoBards Counseling does not work with clients who, in his opinion, he cannot help. In such a case, if appropriate, he will give you referrals that you can contact. If at any point during psychotherapy Michael RoBards, LCSW and RoBards Counseling either assesses that he is not effective in helping you reach the therapeutic goals or perceived you as non-compliant or non-responsive, and if you are available and/or it is possible and appropriate to do, he will discuss with you the termination of treatment and conduct pre-termination counseling. In such a case, if appropriate and/or necessary, he would give you a couple of referrals that may be of help to you. If you request it and authorize it in writing, Michael RoBards, LCSW and RoBards Counseling will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, Michael RoBards, LCSW and RoBards Counseling will give you a couple of referrals that you may want to contact, and if he has your written consent, he will provide her or him with the essential information needed. You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, Michael RoBards, LCSW and RoBards Counseling will provide you with names of other qualified professionals whose services you might prefer.
AUDIO OR VIDEO RECORDING: Unless otherwise agreed to by all parties beforehand, there shall be no audio or video recording of therapy sessions, phone calls, or any other services provided by Michael RoBards, LCSW and RoBards Counseling.
CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 day) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.
I have read the above Office Policies and General Information, Agreement for Psychotherapy Services or Informed Consent for Psychotherapy carefully; I understand them and agree to comply with them:
CONSENT AND RELEASE OF LIABILITY FOR ANIMAL ASSISTED THERAPY
Therapy animals can be a vital part of the treatment team; I hope that you are comfortable with Jack’s presence in your sessions. However, because he is an animal, and not a human, we are responsible for his welfare. In addition, because he is an animal, his behavior cannot always be predictable. Therefore, it is important to discuss in advance the risks and rules needed to insure Jack’s and your safety and health, and try to create as safe a working situation as possible. In addition, it is important to provide you with diligent warning about the potential harm that could be present when working with animals. While I have listed some of these risks below, we cannot foresee all potential problems that may occur. Therefore by signing this form you are releasing Michael RoBards, LCSW from any liability should any injury occur as part of your treatment there.
RISKS:
1. Jack is currently in training; meaning he has not yet been certified to do Animal Assisted Therapy. he still needs to learn some skills to pass his certification test. During his training process, and even once he is certified, you may opt to not have his a part of your session.
Should you choose, he will stay in his room for the duration of your session. Please do not feel obligated to have him participate; he loves relax and take a nap in his room!
2. Animals have their own natural defenses. While I will do everything possible to prevent any injury, it is possible that someone will get scratched or bitten.
3. Animals often use their mouths in play. Therefore, even when playing, it is possible for light biting to occur. When playing with a toy with Jack, he may miss the toy and get your finger. When he realizes this, he releases and does not bite down, but you may still feel his teeth.
4. While Jack has been screened by a veterinarian before commencing to work as a therapy animal, animals do sometimes carry disease. Because your contact is minimal, this risk is very small. Jack is up to date on all of his vaccinations.
5. While Jack is a “hypoallergenic” dog (as he has hair and not fur) there may still be risk for
allergic reaction. Please let me know if you typically have allergies to animals.
RULES:
1. Animals have individual rights, just as each client has rights. Therefore, Jack is allowed to determine if and when he participates with others. While it may be planned to have his in session, he will never be forced to do so.
2. Jack has his own quiet space in the office where he can rest, sleep, or just take a quiet break. He should not be disturbed when he is in this area.
3. Jack should always be treated gently. He should never be hit, have his tail or any other parts pulled, be carried or treated in any other way that is uncomfortable to her.
4. Jack will always need me present in any therapeutic situation.
5. If Jack becomes irritated, scared, or in any way acts in a negative manner, I will put him in a safe place. No other person should touch him at these times.
6. Jack can only be carried by his therapist handler.
7. Because of the unpredictability of animals in unfamiliar situations, clients may not bring their
own animal to be involved in their therapy session.
8. Parents or guardians of children under the age of 10 must remain on the premises during their child’s session.
By signing this release you are stating your acceptance of these rules and risks and agree to accept full liability in the event that Jack harms you or your child in any way in the course of treatment or you or your child is harmed in any way as a result of being on the property of 2815
Taylorsville Road, Suite 101, Louisville, KY 40205 or at any other place while in the presence of Michael RoBards, LCSW and Jack.
Notice of Privacy Practices
THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Confidentiality
As a rule, I will disclose no information about you, or the fact that you are my patient, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, I do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing the attached general consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me.
II. “Limits of Confidentiality”
Possible Uses and Disclosures of Mental Health Records without Consent or Authorization
There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, [some because of policies in this office/agency], and some required by law. If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits. We will discuss these issues now, but you may reopen the conversation at any time during our work together.
I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required:
· Emergency: If you are involved in in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.
· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by Kentucky law to report the matter immediately to the Kentucky Child Protective Services.
· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by Kentucky law to immediately make a report and provide relevant information to the Kentucky Department of Adult Protective Services.
· Health Oversight: Kentucky law requires that licensed social workers report misconduct by a health care provider of their own profession. By policy, I also reserve the right to report misconduct by health care providers of other professions. By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make such a report. If you are yourself a health care provider, I am required by law to report to your licensing board that you are in treatment with me if I believe your condition places the public at risk. Kentucky Licensing Boards have the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.
· Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court. In Kentucky civil court cases, therapy information is not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be “necessary for the proper administration of justice.” In criminal cases, Kentucky has no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if I do an evaluation 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: Under Kentucky law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can be required to provide your records to the magistrate, your attorney or guardian ad litem, an evaluator, or a law enforcement officer, whether you are a minor or an adult.
Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
Records of Minors: Kentucky has a number of laws that limit the confidentiality of the records of minors. For example, parents, regardless of custody, may not be denied access to their child’s records; and evaluators in civil commitment cases have legal access to therapy records without notification or consent of parents or child. Other circumstances may also apply, and we will discuss these in detail if I provide services to minors.
Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission. [This sentence is now required under the HIPAA “Final Rule.”]
III. Patient’s Rights and Provider’s Duties:
· Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
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 seeing me. Upon your request, I will send your bills to another address. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
Right to an Accounting of Disclosures – 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 III of this Notice). On your written request, I will discuss with you the details of the accounting process
.
Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding.
Right to Amend – If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted dot me. In addition, you must provide a reason that supports s your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
Right to a copy of this notice – You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Changes to this notice: I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date . A new copy will be given to you or posted in the waiting room. I will have copies of the current notice available on request.
Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.
WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to Michael RoBards, LCSW and RoBards Counseling that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Michael RoBards, LCSW and RoBards Counseling. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Michael RoBards, LCSW and RoBards Counseling will use his/her clinical judgment when revealing such information. Michael RoBards, LCSW and RoBards Counseling will not release records to any outside party unless s/he is authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client, unless he/she is required by law. While I will do my best to seek your authorization to release the requested information regarding our psychotherapy from you first, in some situations a judge can order the release of the records of your psychotherapy with me or may order me to testify in regard to our therapeutic work.
EMERGENCY: If there is an emergency during therapy, or in the future after termination, where Michael RoBards, LCSW and RoBards Counseling becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, s/he will do whatever s/he can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, s/he may also contact the person whose name you have provided on the biographical sheet.
HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct Michael RoBards, LCSW and RoBards Counseling, only the minimum necessary information will be communicated to the carrier. Michael RoBards, LCSW and RoBards Counseling has no control over, or knowledge of, what insurance companies do with the information s/he submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and may be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.
LITIGATION: Sometimes patients become involved in litigation while they are in therapy or after therapy has been completed. Sometimes patients (or the opposing attorney, in a legal case) want the records disclosed to the legal system. Due to the nature of the psychotherapeutic process and the fact that it often involves making a full disclosure with regard to many matters, clients’ records are generally confidential and private in nature. Patients should know that very serious consequences can result from disclosing therapy records to the legal system. Such disclosures may negatively affect the outcome of custody disputes or other legal matters and may negatively affect the therapeutic relationship. If you or the opposing attorney are considering requesting Michael RoBards, LCSW and RoBards Counseling’s disclosure of the records, Michael RoBards, LCSW and RoBards Counseling will do his/her best to discuss with you the risks and benefits of doing so. As noted in this document, you have the right to review your own psychotherapy records anytime. (See also relevant section above: "WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW")
CONSULTATION: Michael RoBards, LCSW and RoBards Counseling consults regularly with other professionals regarding his clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.
E–MAILS, CELL PHONES, TEXTS, COMPUTERS, AND FAXES: It is very important to be aware that computers and unencrypted emails, texts, and e-fax communications (which are part of the clinical records) can be rather easily accessed by unauthorized people and, hence, can compromise the privacy and confidentiality of such communications. Emails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all emails, texts and e-faxes that go through them. While data on Michael RoBards, LCSW and RoBards Counseling’s laptop is encrypted, emails, texts and e-faxes are not. It is always a possibility that e-faxes, texts, and emails can be sent erroneously to the wrong address and computers. Michael RoBards, LCSW and RoBards Counseling’s laptop is equipped with a firewall, VPN, a virus protection and a password. Also, be aware that phone messages are transcribed and sent to Michael RoBards, LCSW and RoBards Counseling via unencrypted emails. Please notify Michael RoBards, LCSW and RoBards Counseling if you decide to avoid or limit, in any way, the use of email, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted emails, texts or e-faxes or via phone messages, Michael RoBards, LCSW and RoBards Counseling will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and he will honor your desire to communicate on such matters. Please do not use texts, emails, voice mails, or faxes for emergencies.
RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of Michael RoBards, LCSW and RoBards Counseling profession require that s/he keep treatment records for at least _____ years. Please note that clinically relevant information from emails, texts, and faxes are part of the clinical records. Unless otherwise agreed to be necessary, Michael RoBards, LCSW and RoBards Counseling retains clinical records only as long as is mandated by (insert your state) law. If you have concerns regarding the treatment records, please discuss them with Michael RoBards, LCSW and RoBards Counseling. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when Michael RoBards, LCSW and RoBards Counseling assesses that releasing such information might be harmful in any way. In such a case, Michael RoBards, LCSW and RoBards Counseling will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, Michael RoBards, LCSW and RoBards Counseling will release information to any agency/person you specify unless Michael RoBards, LCSW and RoBards Counseling assesses that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, Michael RoBards, LCSW and RoBards Counseling will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.
TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Michael RoBards, LCSW and RoBards Counseling between sessions, please leave a message at the answering service (502)225-3025 and your call will be returned as soon as possible. Michael RoBards, LCSW and RoBards Counseling checks his/her messages a few times during the daytime only, unless s/he is out of town. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away call 24 crisis line at (In Louisville): 211 or (502) 589-4313 or the Police: 911. Please do not use email or faxes for emergencies. Michael RoBards, LCSW and RoBards Counseling does not always check his/her email or faxes daily.
PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee of $150.00 per 55 minute session at the end of each session unless other arrangements have been made. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify Michael RoBards, LCSW and RoBards Counseling if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, Michael RoBards, LCSW and RoBards Counseling will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement, if you so choose. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, Michael RoBards, LCSW and RoBards Counseling can use legal or other means (courts, collection agencies, etc.) to obtain payment.
THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Michael RoBards, LCSW and RoBards Counseling will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Michael RoBards, LCSW and RoBards Counseling may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Michael RoBards, LCSW and RoBards Counseling is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational. Michael RoBards, LCSW and RoBards Counseling provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within his/her scope of practice.
TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, Michael RoBards, LCSW and RoBards Counseling will discuss with you his/her working understanding of the problem, treatment plan, therapeutic objectives, and his/her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their
possible risks, Michael RoBards, LCSW and RoBards Counseling's expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.
Dual Relationships
Despite a common misconception, not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Michael RoBards, LCSW and RoBards Counseling's objectivity, clinical judgment or therapeutic effectiveness or can be exploitative in nature. Michael RoBards, LCSW and RoBards Counseling will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. It is important to realize that in some communities, particularly small towns, small communities, military bases, university campuses, spiritual and rehabilitation communities, etc., multiple relationships are either unavoidable or expected. Michael RoBards, LCSW and RoBards Counseling will never acknowledge working with anyone without his/her written permission. Many clients have chosen Michael RoBards, LCSW and RoBards Counseling as their therapist because they knew him/her before they entered into therapy with him/her and/or were aware of his/her stance on the topic. Nevertheless, Michael RoBards, LCSW and RoBards Counseling will discuss with you, the often-existing complexities, potential benefits and difficulties that may be involved in such relationships. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to communicate to Michael RoBards, LCSW and RoBards Counseling if the dual relationship becomes uncomfortable for you in any way. Michael RoBards, LCSW and RoBards Counseling will always listen carefully and respond accordingly to your feedback. Michael RoBards, LCSW and RoBards Counseling will discontinue the dual relationship if he finds it interfering with the effectiveness of the therapeutic process or your welfare and of course you can do the same at any time.
Minors in Therapy
If you are under eighteen years of age, please be aware that the law may give your parents or guardians the right to obtain information about your treatment and/or examine your treatment records. It is my policy to request a written agreement from your parents or guardians indicating that they consent to give up access to such information and/or, to your records. If they agree, I will provide them only with general information about our work together subject to your approval, or, if I feel it is important for them to know in order to make sure that you and people around you are safe. If I think it is appropriate, I will involve them if I feel that there is a high risk that you will seriously harm yourself or another/others. Before giving them any verbal or written information, I will discuss the matter with you, if possible. I will do the best I can to resolve any differences that you and I may have about what I am prepared to discuss.
Group Therapy
In group therapy, it is of utmost important that all members maintain confidentiality and neither disclose the content of sessions nor the identity of fellow group members. It is highly recommended that any meaningful exchange outside the group also be discussed in the group. In group therapy, the other members of the group are not therapists. They are not regulated by the same ethics and laws that bind your therapist. The limits of confidentiality and the reporting laws have been outlined earlier in this document. While the expectation is that all group members will maintain confidentiality regarding anything said in the group, you cannot be certain that they will. You are ultimately responsible for what you say and what you think, feel, or do with the feedback you receive in the group.
TERMINATION: As set forth above, after the first couple of meetings, Michael RoBards, LCSW and RoBards Counseling will assess if he can be of benefit to you. Michael RoBards, LCSW and RoBards Counseling does not work with clients who, in his opinion, he cannot help. In such a case, if appropriate, he will give you referrals that you can contact. If at any point during psychotherapy Michael RoBards, LCSW and RoBards Counseling either assesses that he is not effective in helping you reach the therapeutic goals or perceived you as non-compliant or non-responsive, and if you are available and/or it is possible and appropriate to do, he will discuss with you the termination of treatment and conduct pre-termination counseling. In such a case, if appropriate and/or necessary, he would give you a couple of referrals that may be of help to you. If you request it and authorize it in writing, Michael RoBards, LCSW and RoBards Counseling will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, Michael RoBards, LCSW and RoBards Counseling will give you a couple of referrals that you may want to contact, and if he has your written consent, he will provide her or him with the essential information needed. You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, Michael RoBards, LCSW and RoBards Counseling will provide you with names of other qualified professionals whose services you might prefer.
AUDIO OR VIDEO RECORDING: Unless otherwise agreed to by all parties beforehand, there shall be no audio or video recording of therapy sessions, phone calls, or any other services provided by Michael RoBards, LCSW and RoBards Counseling.
CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 day) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.
I have read the above Office Policies and General Information, Agreement for Psychotherapy Services or Informed Consent for Psychotherapy carefully; I understand them and agree to comply with them:
CONSENT AND RELEASE OF LIABILITY FOR ANIMAL ASSISTED THERAPY
Therapy animals can be a vital part of the treatment team; I hope that you are comfortable with Jack’s presence in your sessions. However, because he is an animal, and not a human, we are responsible for his welfare. In addition, because he is an animal, his behavior cannot always be predictable. Therefore, it is important to discuss in advance the risks and rules needed to insure Jack’s and your safety and health, and try to create as safe a working situation as possible. In addition, it is important to provide you with diligent warning about the potential harm that could be present when working with animals. While I have listed some of these risks below, we cannot foresee all potential problems that may occur. Therefore by signing this form you are releasing Michael RoBards, LCSW from any liability should any injury occur as part of your treatment there.
RISKS:
1. Jack is currently in training; meaning he has not yet been certified to do Animal Assisted Therapy. he still needs to learn some skills to pass his certification test. During his training process, and even once he is certified, you may opt to not have his a part of your session.
Should you choose, he will stay in his room for the duration of your session. Please do not feel obligated to have him participate; he loves relax and take a nap in his room!
2. Animals have their own natural defenses. While I will do everything possible to prevent any injury, it is possible that someone will get scratched or bitten.
3. Animals often use their mouths in play. Therefore, even when playing, it is possible for light biting to occur. When playing with a toy with Jack, he may miss the toy and get your finger. When he realizes this, he releases and does not bite down, but you may still feel his teeth.
4. While Jack has been screened by a veterinarian before commencing to work as a therapy animal, animals do sometimes carry disease. Because your contact is minimal, this risk is very small. Jack is up to date on all of his vaccinations.
5. While Jack is a “hypoallergenic” dog (as he has hair and not fur) there may still be risk for
allergic reaction. Please let me know if you typically have allergies to animals.
RULES:
1. Animals have individual rights, just as each client has rights. Therefore, Jack is allowed to determine if and when he participates with others. While it may be planned to have his in session, he will never be forced to do so.
2. Jack has his own quiet space in the office where he can rest, sleep, or just take a quiet break. He should not be disturbed when he is in this area.
3. Jack should always be treated gently. He should never be hit, have his tail or any other parts pulled, be carried or treated in any other way that is uncomfortable to her.
4. Jack will always need me present in any therapeutic situation.
5. If Jack becomes irritated, scared, or in any way acts in a negative manner, I will put him in a safe place. No other person should touch him at these times.
6. Jack can only be carried by his therapist handler.
7. Because of the unpredictability of animals in unfamiliar situations, clients may not bring their
own animal to be involved in their therapy session.
8. Parents or guardians of children under the age of 10 must remain on the premises during their child’s session.
By signing this release you are stating your acceptance of these rules and risks and agree to accept full liability in the event that Jack harms you or your child in any way in the course of treatment or you or your child is harmed in any way as a result of being on the property of 2815
Taylorsville Road, Suite 101, Louisville, KY 40205 or at any other place while in the presence of Michael RoBards, LCSW and Jack.
Notice of Privacy Practices
THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Confidentiality
As a rule, I will disclose no information about you, or the fact that you are my patient, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, I do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing the attached general consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me.
II. “Limits of Confidentiality”
Possible Uses and Disclosures of Mental Health Records without Consent or Authorization
There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, [some because of policies in this office/agency], and some required by law. If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits. We will discuss these issues now, but you may reopen the conversation at any time during our work together.
I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required:
· Emergency: If you are involved in in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.
· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by Kentucky law to report the matter immediately to the Kentucky Child Protective Services.
· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by Kentucky law to immediately make a report and provide relevant information to the Kentucky Department of Adult Protective Services.
· Health Oversight: Kentucky law requires that licensed social workers report misconduct by a health care provider of their own profession. By policy, I also reserve the right to report misconduct by health care providers of other professions. By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make such a report. If you are yourself a health care provider, I am required by law to report to your licensing board that you are in treatment with me if I believe your condition places the public at risk. Kentucky Licensing Boards have the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.
· Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court. In Kentucky civil court cases, therapy information is not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be “necessary for the proper administration of justice.” In criminal cases, Kentucky has no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if I do an evaluation 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: Under Kentucky law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can be required to provide your records to the magistrate, your attorney or guardian ad litem, an evaluator, or a law enforcement officer, whether you are a minor or an adult.
Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
Records of Minors: Kentucky has a number of laws that limit the confidentiality of the records of minors. For example, parents, regardless of custody, may not be denied access to their child’s records; and evaluators in civil commitment cases have legal access to therapy records without notification or consent of parents or child. Other circumstances may also apply, and we will discuss these in detail if I provide services to minors.
Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission. [This sentence is now required under the HIPAA “Final Rule.”]
III. Patient’s Rights and Provider’s Duties:
· Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
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 seeing me. Upon your request, I will send your bills to another address. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
Right to an Accounting of Disclosures – 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 III of this Notice). On your written request, I will discuss with you the details of the accounting process
.
Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding.
Right to Amend – If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted dot me. In addition, you must provide a reason that supports s your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
Right to a copy of this notice – You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Changes to this notice: I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date . A new copy will be given to you or posted in the waiting room. I will have copies of the current notice available on request.
Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.
