I understand that your health care information, including psychotherapy appointments, is personal. I am committed to maintaining the confidentiality of this information and providing you with information regarding my privacy practices.
Information about your appointments is confidential and cannot be disclosed to others without your written consent. We comply with state and federal laws regulating confidentiality as well as professional ethical codes. There are some exceptions to confidentiality, typically involving imminent risk of self-harm or abuse of others.
If you have any questions or concerns about our confidentiality policies, please contact (618) 660-0537. I have chosen to adopt some of the provisions of the Health Insurance Portability and Accountability Act (HIPAA) because they represent excellent standards of professional practice in regards to privacy and confidentiality.
I may use or disclose your protected health information (PHI) for treatment and health care operations purposes only with your written authorization. I may also use or disclose PHI for purposes outside of treatment or health care operations when your written authorization is obtained. You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that we have relied on that authorization in providing services on your behalf.
I may use or disclose PHI without your consent or authorization in the certain circumstances, including the following:
If your counselor has reasonable cause to believe a child known to him/her in his/her professional capacity may be an abused child or a neglected child, your counselor must report this belief in accordance with the Abused and Neglected Child Reporting Act.
Adult and Domestic Abuse
If your counselor has reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, he/she must report this belief in accordance with the Illinois Elder Abuse and Neglect Act.
Serious Threat to Health or Safety
Your rights under HIPPA
The following specifies your rights regarding this authorization under the Health Insurance Portability and Accountability Act of 1996, as amended from time to time (“HIPAA”).
Tell your counselor if you do not understand this authorization, and he/she will explain it to you.
You have the right to revoke or cancel this authorization at any time, except: to the extent that information has already been released based on the authorization this authorization was obtained as a condition of obtaining insurance coverage for services. *to revoke or cancel this authorization, you must submit your request in writing to your counselor and your insurance company, if applicable.
You may refuse to sign this authorization. If you refuse to sign this authorization, your provider has the right to decide not to treat you or accept you as a client in their practice.
Once the information about you leaves this office according to the terms of this authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA.
If this office initiated this authorization, you MUST receive a copy of the signed authorization.
Special Instructions for Completing this Authorization for the Use and Disclosure of Psychotherapy Notes:
medication prescription and monitoring
counseling sessions start and stop times
the modalities and frequencies of treatment furnished the results of clinical tests
any summary of: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.