HIPAA FORM

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

Health Insurance Portability and Accountability Act

This document (the Agreement) contains important information about professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and healthcare operations. HIPAA requires that I (the practitioner) provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and somewhat complex, it is very important that you read them carefully. We can discuss any questions you have about the procedures at this time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless I have taken action in reliance on it; if there are obligations imposed by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.

LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communications between a patient and a practitioner. 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. There are other situations that require only that you provide written, advanced consent. Your signature on this Agreement provides consent for those activities, as follows:

I may occasionally find it helpful to consult other practitioners, health professionals, and/or supervisor(s) about a case. During a consultation, I make every effort to avoid revealing the identity of a patient. The other professionals that I may consult with are also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (AKA “PHI”). No identifying information such as name, date of birth, or address will be shared with anyone. All health professionals, interns, and student practitioners are bound by the same rules of confidentiality. If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her/them, or to contact family members or others who can help provide protection. There are some situations where we are permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning the professional services I provided you; the physician-patient privilege law protects such information. I cannot provide any information without your or your legal representative’s written authorization, or court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.

  • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
  • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are very unusual in practice.
  • If I have reason to believe that a child under 18 who I have seen for treatment is or has been the victim of injury, sexual abuse, neglect, or deprivation of necessary medical treatment, the law requires that I file a report with the appropriate government agency, usually the Office of Child Protective Services. Once such a report is filed, I may be required to provide additional information.
  • If I have reason to believe that any adult client who is either vulnerable and/or incapacitated and who has been the victim of abuse, neglect, or financial exploitation, the law requires that we file a report with the appropriate state official, usually a protective services worker. Once such a report is filed, I may be required to provide additional information.
  • If a client communicates an explicit threat of imminent serious physical harm to a clearly identified or identifiable victim, and we believe that the patient has the intent and ability to carry out such a threat, I must take protective actions that may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If such a situation arises, I will make every effort to discuss it with you before taking any action and will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential issues, it is important that we discuss any concerns that you may have now or in the future. In situations where specific advice is required, formal legal advice may be required.

PROFESSIONAL RECORDS

The laws and standards of the profession require that I keep protected health information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and/or others, or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your clinical record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence.

PATIENT RIGHTS

HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include: requesting that I amend your record, requesting restrictions on what information from your clinical record is disclosed to others, requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized, determining the location to which protected information disclosures are sent, having any complaints you make about our policies and procedures recorded in your records and the right to a paper copy of this agreement. I am happy to discuss any of these rights with you.

NO HEALTH PLAN COVERAGE/PAYMENT DUE AT TIME OF SERVICE

Cape EFT Associates does not participate in any health care or insurance reimbursement plans.  Payment is due at time of service.

MINORS & CLIENTS

Clients under 18 years of age who are not emancipated and believe their parents should not be informed of treatment must be aware that the law may allow parents to examine their child’s treatment records.

ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE (HIPAA)

I acknowledge that I have received a copy of the Notice of Privacy Practice for Protected Health

Information (HIPAA).

 

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Client Or Legally Authorized Individual Signature

 

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Printed Name

 

Date _________________________________