The following material will provide you with important information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. The notice of Privacy Practices, which is attached to this agreement, explains HIPAA and its application to your personal health information.
Client Rights
HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of Protected Health Information (PHI). These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to, nor authorized; determining the location to which PHI disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy. We will be happy to discuss any of these rights with you.
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to that information. Please review it carefully.
We are required by applicable federal and state laws to maintain the privacy of your health information. We are also required to give you a copy of this Notice about our privacy practices, legal obligations, and your rights concerning your Protected Health Information (PHI). We must follow the privacy practices that are described in this Notice (which may be amended from time to time).
I. Uses and Disclosures of Protected Health Information (PHI)
A. Permissible Uses and Disclosures Without Your Written Authorization: We 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: We may use PHI in order to provide treatment to you.
Payment: We may use or disclose PHI so that services you receive are appropriately shared with your health plan. We may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.
Health Care Operations: We may use and disclose PHI in connection with health care operations, including quality improvement activities, accreditation, certification, licensing, or credentialing activities.
Required or Permitted by Law: We may use or disclose PHI when we are required or permitted to do so by law. For example, we may disclose PHI to the extent necessary to appropriate authorities if we reasonably believe that you are a possible serious threat to yourself or 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 law enforcement officials in response to a court order or other lawful process; disclosures to military or national security agencies, coroners, or otherwise as authorized by law.
B. Uses and Disclosures Requiring Your Written Authorization
Psychotherapy Notes: Notes recorded by your therapist documenting the contents of a counseling session with you (“Psychotherapy Notes”) will be used only by your therapist and will not otherwise be used or disclosed without your written authorization.
Marketing Communications: We will not use your PHI 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 we can send PHI to your medical doctor, school, or attorney. You may revoke any such authorization at any time.
II. Your Individual Rights
A. Right to Inspect and Copy. You may request access to your medical record and billing records maintained by your therapist in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, we may deny access to your records. We may charge a fee for the costs of copying and sending you any records requested.
B. Right to Alternative Communication. You may request, and we will accommodate whenever possible, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.
C. Right to Request Restrictions. You have the right to request a restriction on PHI used for disclosure of treatment, payment, or health care operations. You must request any restriction in writing addressed to me as indicated below. We are not required to agree to any such restriction you may request.
D. Right to Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made by me. 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.
E. Right to Request Amendment. You have the right to request that we amend your health information. Your request must be made in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
F. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to your therapist at any time.
G. Questions and Complaints. We strive to provide quality services in a caring and professional manner. We understand, however, that disagreements or complaints can occur. We encourage you to discuss these directly with your therapist in order to rectify the matter. We will make every effort to address your concerns; however, if you find the issue unresolved, you may file a complaint with the Secretary of Health and Human Services in your state.
III. Effective Date and Changes to this Notice
A. Effective Date. This notice is effective on September 1, 2015.
B. Changes to this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will provide a new copy of the Notice at your next appointment.
Emergency Statement and Resources
Should you find yourself or a loved one in an emergency, please seek assistance immediately. Emergencies include, but may not be limited to, self-harm/suicidal thoughts, threats, and attempts, physical or psychological concerns of medication, fear of harming self or others, inability to keep yourself or family safe around aggressive or out-of-control behaviors or rage.
Please note that I do NOT provide crisis counseling and recommend you seek assistance in the closest emergency room for an evaluation and/or contact your local crisis intervention team by calling 911.
Limits of Confidentiality
The confidentiality of your records is highly valued. The law protects the privacy of communications between a client and therapist, although there are some situations excluded by law. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA and/or other federal or state laws.
Limits to preserving confidentiality include the following:
If we know or have reason to suspect that a child under 18 years of age is being or has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law mandates that a verbal and written report is filed with the Department of Children and Families. Once a report is filed, we may be required to provide additional information.
If we believe that there is a clear and immediate probability of physical harm to the client, other individuals, or to society, we may be required to disclose information to take protective action, including communicating the information to the potential victim(s), and/or appropriate family member(s), and/or the police.
At times we may find it helpful to consult with other professionals regarding your care; however, without a signed release of information, your identity will remain anonymous so that confidentiality is maintained.
If such situations arise, we will make a reasonable effort to fully discuss the matter with you before taking any action and we will limit my disclosure to what is necessary.
Clinical Records
The laws and standards of our profession require that we keep Protected Health Information about you in your clinical records. Except in unusual circumstances that disclosure would potentially endanger you and/or others, or the information makes reference to another person (other than a health provider), or we believe access is reasonably likely to cause you or others substantial harm, you may examine and/or receive a copy of your clinical record, if you request it in writing. Clinical records may be misinterpreted or upsetting to an untrained reader. For this reason, we recommend that you initially review them in your therapist’s presence or have them forwarded to another mental health professional so you can discuss the contents.
Minors and Parents
Parents of clients under the age of 18 who are not emancipated should be aware that the law may allow parents to examine their child’s treatment records. Children between the ages of 13 and 17 may independently consent to (and control access to the records of) diagnosis and treatment in a crisis situation. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, your therapist may request an agreement with minors (over 12) and their parents about access to information. This agreement provides that during treatment, your therapist will provide you with only general information about the progress of the treatment and the child’s attendance at scheduled sessions. The therapist may also provide you with a summary of their child’s treatment when it is complete. In these cases, your therapist may require the child’s authorization to release information, unless we feel the child is in danger or is a danger to someone else, in which case, your therapist will notify you of any concerns. Before giving you any information, your therapist will discuss the matter with the child, if possible, and do his/her best to manage any objections he or she may have.
The federal law protecting the release of drug and alcohol information is more stringent for adults and minor children. While we recognize the serious parental concerns in this regard, we cannot release such information without informed consent from an adult client, as well as children 14 years of age and older.
By presenting your minor child for treatment, you are representing and affirming that you have legal parental authority to do so. Unless parental rights have been terminated, or there have been other restrictions imposed by the court or law, you are affirming that both parents have equal rights to information about diagnosis and treatment under the law.
Electronic Correspondence
Email and texting are convenient mediums of communication and effective ways to handle administrative issues like scheduling, but neither are 100% secure.
Some of the potential risks you might encounter if we email or text include:
Misdelivery of email or text to an incorrectly typed address or phone number.
Email accounts can be ‘hacked’ giving a 3rd party access to email content and addresses.
Email providers and phone providers keep a copy of each email or text on their servers, where it might be accessible to employees, etc.
Email Policy: Email is a convenient way to maintain a stream of communication between clients, especially with parents who are not present during their child’s individual session. In my experience, this ongoing communication is beneficial for the client, guardians, and provider.
Texting Policy: Texting is acceptable ONLY to communication regarding non-clinical issues. These include topics such as scheduling an appointment, changing an appointment, notification of running late to an appointment, receipt requests, and directions to the office. Texts regarding clinical issues, such as a family issues, personal difficulties, etc., are not confidential per reasons stated above regarding phone companies and governments ability to intercept them.
Social Media and the Internet
We would like to address boundaries regarding social media and any other information online.
NO online searches will be made by us on you or your family for the purpose of gathering personal information. Client may be researching the professional background of a therapist and other service/practice information.
Client and therapist will NOT request or agree to be ‘friends’ on social media sites. Clients may ’like’ or ‘follow’ social media pages offered by the therapist as a part of their professional work.
Any client comments made on therapist’s professional social media site that potentially disclose a client-therapist relationship will be removed immediately.
Susanna Carlson LCSW CST uses social media sites for professional purposes.
Online therapy
Therapy will be conducted via a HIPAA compliant video chat platform. Prior to our first online therapy appointment, we will email you a link to the designated virtual room. Please note we are not able to use Skype, FaceTime, or others, as they are not HIPAA compliant.
It is important that you find a private and comfortable place for the sessions without being interrupted, distracted or overheard. Ensure your ability to connect to the internet from the location you choose in order to engage in therapy sessions as scheduled.
We conduct online therapy to clients who live in California, New York, Connecticut, and Utah, states where we are a licensed provider (LCSW Licensed Clinical Social Worker) of mental health services. If you are interested in receiving services outside these state lines, we are available to discuss options for professional coaching. Please note this does not apply to those living abroad.
Adding technology to the therapeutic relationship can lead to complications beyond the control of either the therapist of the client. If such technological problems (such as a lost internet connection) occur, the therapy session will continue by telephone. This will not change the amount of payment due for the session.
Your insurance many not cover therapy sessions conducted online. Please contact them directly for details about out-of-network coverage specifically for virtual sessions and if you are unsure about limitations for using your Health Savings Account or ‘flex account’.
Right to request a Good Faith Estimate
A Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit U.S. Department of Health and Human Services (HHS) at www.cms.gov/nosurprises/consumers or call 1-800-985-3059.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than the Good Faith Estimate, you have the right to dispute the bill.
You may contact your health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059.