We are required by The Health Insurance Portability & Accountability Act of 1996 (HIPAA) to provide confidentiality for all medical/mental health records and other individually identifiable health information in our possession. This Notice is to inform you of the uses and disclosures of confidential information that may be made, and of your individual rights and our legal duties with respect to confidential information.

Ways in Which We May Use and Disclose Your Protected Health Information

We may use and disclose at our discretion your medical records for each of the following purposes only: treatment, payment, and health care operations.

  1. Treatment means providing, coordinating, or managing mental health care and related services. For example - use or disclosure by the health care provider in training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling.
  2. Payment means activities such as obtaining payment for the mental health care services we provide for you either from your insurance or another third party payer. For example - we may include information with a bill to a third-party payer that identifies you, your diagnosis, and procedures performed.
  3. Health care operations include the business aspects of operating the counseling ministry. For example - to evaluate our treatment and services, or to evaluate our staff's performance while caring for you.

We may contact you to provide appointment reminders or other services that may be of interest to you. We will disclose your protected health information to any person you identify that is involved in your care or payment for your care. For example - a family member, relative, close friend, pastor, or pastor's representative with whom you have asked us to communicate.

We will use and disclose your protected health information when required by federal, state, or local law. There are certain situations in which as a therapist I am required by ethical standards to reveal information obtained during therapy to other persons or agencies - even if you do not give permission. These situations might include the following: (a) If you threaten grave bodily harm or death to yourself or another person, I am required by ethical standards to inform the intended victim and/or appropriate law enforcement agencies; (b) if you report to me your knowledge of physical or sexual abuse of a minor child or of an elder (over 65) or any sexual conduct/contact with a minor, I am required by law to inform the appropriate child welfare or social agency which may then investigate the matter; (c) if I am required by a court of law (court order) to turn over records to the court or I am ordered to testify regarding those records.

Any other uses and disclosures will be made only with your written authorization. You will be provided with an authorization form upon request. A separate form will be needed for each request for release of information. The authorization for release of records is valid until expires or is revoked. You may revoke an authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.