THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. / USES AND DISCLOSURES:
TREATMENT – Your health information may be used by our providers and staff members or may be disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.
PAYMENT – Your health information may be used to seek payment from your health plan, other sources of coverage such an automobile insurer, or credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
HEALTH CARE OPERATIONS – Your health information may be used as necessary to support the day-to-day activities and management of Healing Places Counseling Center. For example, information on the services you received may be used to support budgeting and financial reporting and activities to evaluate and promote quality to ensure that our practice is meeting state and federal guidelines and laws designated to protect your health care information.
LAW ENFORCEMENT – Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting. For example, any known or reasonably suspected cases of child abuse or neglect, any known or suspected intentions of harming oneself (suicide), and/or any known or suspected intentions of harming others.
PUBLIC HEALTH REPORTING – Your health information may be disclosed to public health agencies as required by law. For example, our practice is required to report certain communicable diseases to the State of Washington Departmentof Health.
BUSINESS ASSOCIATES – The following companies may have access to your Protected Health Information for the purpose of carrying out Treatment, Payment, and/or Health Care Operations: Prestige Medical Billing Company, Inc.
OTHER USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION – Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a disclosure or use of your information, you may submit a written revocation of the authorization. However, your decision to revoke your authorization will not affect or undo any disclosure or use that occurred before you notified this practice of your decision.
Additional Uses of Information:
APPOINTMENT REMINDERS – When applicable, your health information will be used by our staff to call / send you appointment reminders.
INFORMATION ABOUT TREATMENT – Your health information may be used to send you information on the treatment and management of your health condition that you may find of interest. We may also send you information describing other health-related goods and services that we believe may interest you.
INDIVIDUAL RIGHTS - YOU HAVE CERTAIN RIGHTS UNDER THE FEDERAL PRIVACY STANDARDS. THESE INCLUDE:
The right to request restrictions on the disclosure and use of your protected health information; The right to receive confidential communications concerning your medical condition and treatment; The right to inspect and copy your protected health information; The right to request an amendment or to submit corrections to your protected health information; The right to receive an accounting of how and to whom your protected health information has been disclosed; The right to receive a printed copy of this notice.
PROVIDER / OFFICE DUTIES – We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices that are outlined in this notice.
RIGHT TO REVISE PRIVACY PRACTICES – As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice at your next office visit. These revised policies and practices will be applied to all protected health information we maintain.
RIGHT TO INSPECT PROTECTED HEALTH INFORMATION – As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting your individual practitioner or the front office. If you request a copy of your records, the following fees will be assessed: $24 Clerical fee, $1.09 per page fee for the first 30 pages and then $0.82 per page for any pages 31 and over. This fee must be paid prior to the copies being released.
COMPLAINTS AND CONTACT PERSON – If you would like to submit a comment or complaint about our privacy practices or obtain additional information about our privacy practices, you can do so by sending a letter outlining your concerns to the person listed below. You will not be penalized or otherwise retaliated against for filing a complaint.
Relationships with a professional therapist are protected by law. Your (or your child’s) identity, the fact that you are being seen in psychotherapy, and the content of our communications are kept completely confidential, except:
• When you give written permission to release information to an insurance company, to another professional, or to another third party.
• When you give written permission or there is a court order for records that are subpoenaed for legal reasons
• When it is required by law, including cases of child abuse or neglect, dependent adult or elder abuse or neglect, and imminent danger to self or others
• In addition, your health plan may require that I disclose certain information to them or their managed care review organization, in order for them to pay for services provided to you or your child. Your confidentiality is of great importance, and only information that is essential for authorization of services is released from our office to your health plan or the review organization. Your signature below will serve as your consent to this limited release of information to your health plan or their managed care provider.
• You have the right to request a copy of your medical record. This request must be made in writing and, if you request a copy of the information, you may be charged a fee for the associated costs (for example, copying). I may deny your access to this information under certain circumstances, but in some cases, you may have the decision reviewed.
CONSENT TO TREATMENT
Most people who participate in psychotherapy benefit from it. Like most kinds of health care, this kind of treatment requires a very active effort on your part. In addition, there may be certain kinds of risks involved. For example, the therapy process can be challenging and may at times involve experiencing uncomfortable feelings, engaging in difficult discussions, or facing difficult aspects of your life. Nevertheless, most people find that the benefits outweigh the risks. In fact, sometimes there can be more risks associated with not participating in therapy.
It is important that you participate in this treatment willingly. If you have any questions or concerns about anything contained in this form, about the services being provided to you (or your child), or about treatment options, please voice your questions or concerns in therapy. You may also contact the Department of Health in order to file a complaint or to obtain a copy of the acts of unprofessional conduct. Inquires may be made in writing to the Department of Health, Business and Professional Administration, PO BOX 9012, Olympia, Washington, 98405-8001, or by phone (360) 753-1761. However, before filing a complaint, or for more information or assistance regarding the privacy of your health information, please contact Healing Places Counseling Center at 253-564-4233 or by mail at the address listed above.
Your therapist’s goal is to assist you in obtaining your desired therapeutic outcomes. If you have any questions or concerns about any aspect of your therapy, please discuss them with your therapist. If you elect to terminate or suspend treatment, please discuss your decision with your therapist so that he or she can bring sufficient closure to your work together. In your final session, you and your therapist will discuss your progress, and explore ways in which you can continue to utilize the skills and knowledge you have gained through therapy. You and your therapist can also discuss any referrals that you may require at that time.
Your therapist will check his or her confidential voicemail regularly during working hours Monday – Friday.
She will generally be able to return calls within 1 business day. If your therapist is not available and you require immediate attention, please call the Pierce County Crisis Line, available 24 hours a day, at (253) 396-5180 or (800) 576-7764.
Phone calls to your therapist are for scheduling purposes and urgent clinical matters. Phone calls longer than 15 minutes will incur a fee.