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Please print, read, and keep for your files a copy of my HIPAA form. This document outlines the various rights you have as the client regarding access to and control of your Personal Health Information (PHI). It also articulates how as a clinician, I am required by law, along with other health care providers, to maintain the privacy of your PHI and to provide you with notice of my legal duties and Privacy Practices. 



The Health Insurance Portability and Accountability Act (HIP AA) is a federal law, part of which became effective on April 14, 2003. It requires, among other things, that the privacy of health information, be safeguarded in very specific ways with regard to its use, disclosure and transmission. This individually identifiable information is referred to as Protected Health Information (PHI).


HIP AA also delineates various rights you as the client have regarding access to and control of your PHI. State laws and professional Codes of Ethics may supersede the HIP AA requirements in those cases where state laws or ethical    codes may be more protective, or where your rights may be more expansive.


As a clinician, I am required by law, along with other health care providers to maintain the privacy of your PHI and to provide you with notice of my legal duties and Privacy Practices. I must abide by the terms of this notice and may            reserve the right to change the terms of this Notice of Privacy Practices at any time as changes in federal and state laws require. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. Any new Notice of Privacy Practices will be effective for all PHI that is maintained at that time. In such case, you will be provided with a copy of the         revised Notices at your next scheduled appointment, or at your request, a copy may be sent via US mail.







  1. Uses and Disclosures for Treatment, Payment, and Health Care Operations


I may use of disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. Your consent of authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposed outside of treatment payment and health care operations. I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. Psychotherapy notes are notes that I have made about our conversation during a private, group, joint, or family counseling session, and that I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on an authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.



I may use or disclose PHI without your consent or authorization in the following circumstances:


~Child Abuse:


If, in my professional capacity, I know or suspect that a child under 18 years of age or a mentally retarded, developmentally disabled, or physically impaired child under 21 years of age has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect, I am required by law to immediately report that knowledge or suspicion to the Ohio Public Children’s Services Agency, or a municipal or county peace officer.


~Adult and Domestic Abuse:


If I have reasonable cause to believe that an adult is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect, or exploitation,

I am required by law to immediately report such belief to the county department of Job and Family Services.


~Judicial or Administrative Proceedings:


If you are involved in a court proceeding and a request is made for information about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law and I will not release this information without written authorization from you or your persona legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be formed in advance if this is the case.


~Serious Threat to Health or Safety:


If I believe you pose a clear and substantial risk of imminent serious harm to         yourself or another person, I may disclose your relevant confidential information to public authorities, the potential victim, other professionals, and/or   your family in order to protect against such harm. If you communicate to me an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly identifiable victims, and I believe you have the intent and ability to carry out the threat, then I am required by law to take one or more of the following actions in a timely manner:

1) take steps to hospitalize you on an emergency basis,

2) establish and undertake a treatment plan calculated to eliminate the possibility that you will carry out the threat, and initiate arrangements for a second opinion risk assessment with another mental health professional,

3) communicate to a law enforcement agency and, if feasible, to the potential victim(s), or victim’s parent or guardian of a minor, all of the following information: a) the nature of the threat, b) your identity, and c) the identity of the potential victim(s).


~Worker’s Compensation


If you file a worker’s compensation claim, I may be required to give your mental health information to relevant parties and officials.




Patients Rights:


Right to Request Restrictions~You have the right to request restrictions on certain            uses and disclosures of protected health information about you. However, I am   not required to agree to a restriction upon your request.


Right to Receive Confidential Communications by Alternative Means and at

Alternative Locations~ You have the right to request and receive confidential communications of PHI by alternative means 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).


Right to Inspect and Copy~you have the right to inspect or obtain and copy

(or both) of PHI and psychotherapy notes in my mental health and billing records

used to make decisions for you as long as the Bill is maintained in the record. I may deny access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request process.


Right to Amend~ You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request I will discuss with you the details of the amendment process.


Right to Accounting~ You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this Notice). On your request, I will discuss with you the details of the accounting process.


Right to a Paper Copy~ You have the right to obtain a paper copy of the notice from me upon my request, even if you have agreed to receive the notice electronically.




I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.


I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.


If I revise my policies and procedures, I will notify you by mail.




If you are concerned that I have violated your privacy rights, or you disagree, with a decision I made about access to your records, you may contact me at (216) 245-7440.


You may also send a written complaint to the Secretary of the U.S. Department of             Health and Human Services.




This notice will go into effect April 14, 2003.I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by posting a copy in my office.  A copy of the posting will be available on request.