confidentiality disclosure form You can download this and print out.
“Notice of Privacy Practices”
+ Consent to Accept This Office’s Confidentiality Policies
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.
Uses and Disclosures of Information Requiring Your Authorization or Consent.
- I will disclose no information about you.
- I will not disclose that you are my patient, without your written consent.
- My formal Therapy Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress 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.
- “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 required by law.
If you wish to receiveTherapies services from me, you must sign the attached form indicating that you understand and consent to 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
- 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 law to report the matter immediately to Social 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 law to immediately make a report and provide relevant information to the Welfare or Social Services.
- Health Oversight: By law I am required that I report misconduct by a therapy provider of my 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 health provider of any profession, I am required to explain to you how to make a report to the licensing board. If you are yourself a health care provider, I am required by law to report to your licensing board if I believe your condition places the public at risk.
- 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 law, and I will not release information unless you provide written authorization or a judge issues a court order. 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. Therapy information or records are not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue (e.g., if you sue someone for mental/emotional damages), or in any case in which the judge deems the information to be “necessary for the proper administration of justice.” In criminal cases, Virginia 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 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 lawyer or guardian or law enforcement officer, whether you are a minor or an adult.
- Records of Minors: 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 CSB 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.
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 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 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.
- 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 to 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. 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.
EFFECTIVE DATE: _________________
Patient’s Acknowledgement of
Receipt of Notice of Privacy Practices
Please sign, print your name, and date this acknowledgement form.
I have been provided a copy of Della Luce Notice of Privacy Practices.”
We have discussed these policies, and I understand that I may ask questions about them at any time in the future.
I consent to accept these policies as a condition of Holistic Therapy services.
Printed Name: ___________________________________________________________________