I understand that, consistent with the HIPAA requirements, consent to treatment and consent to release will expire after twelve months and I may revoke such consent at will, although revocation is not retroactive.
I have been informed of and read the preceding information and agree to it. I authorize treatment of the person named below and agree to pay all fees for services rendered by my therapist.
If you have any questions or would like additional information, please feel free to ask.
ATTESTING THAT I UNDERSTAND THE ABOVE AND AGREE TO THERAPY UNDER THE ABOVE LIST OF DISCLOSURES I HAVE SIGNED BELOW:
—This notice describes how your health information may be used and disclosed and how you can access this information. Please review it carefully. You have a right to feel knowledgeable about how I may use medical information about you and to know what your rights are concerning maintaining your privacy, to give you this notice, and to follow the terms of this notice.
—The law permits me to use or disclose your health information as involved in your treatment.
—I may use or disclose your health information for payment of your services. For example, I may send a report of your progress to the insurance company.
—I may use or disclose your health information for normal healthcare operations.
—I may share health care information with business associates, such as a billing service and/or a website/software developer (Paul Mojica Tech). Any business/billing service must agree to protect your privacy under HIPAA.
—I may use your information to contact you. For example, I may call to remind you of your appointments. If you do not answer the phone, I may leave a message for you. If you prefer to use a machine or with the person who answers the telephone:
—In an emergency, I may disclose your health information to a family member or another person responsible for your care.
—I may release some or all of your health information when required by law.
—I may disclose some or all of your health information if there is a threat to use health information without your prior written authorization.
—You may request in writing that I not use or disclose your health information as described above. I will let you know if we can fulfill your request.
—You have the right to know of any use or disclosure made with your health information beyond the above normal uses. As I will need to contact you from time to time, I will use whatever address or telephone number you prefer. You have the right to request that I only mail information to a specific address or that I call only a specific telephone number.
—You have the right to inspect and receive a copy of your health information, with a few exceptions. A written request regarding the information you want to see is required. If you also want a copy of your records, you may be charged you a reasonable fee for the copies.
—You have the right to request an amendment or change to your health information. Please provide your request to make changes to your health information in writing. If I agree to make the changes you request or notify you in writing that I cannot make your changes and tell you why. I may deny any of the details of this notice are changed, you will be notified in writing.
Acknowledgment
I have received a copy of Kirstin R. Abraham, LCSW's notice of privacy practices.