Health Insurance Portability and Accountability Act (HIPAA)
Carlene M. Wentworth, Ph.D., LPC
864.760.3150
[email protected]
Health Insurance Portability and Accountability Act (HIPAA) Confidentialty Information you share during your sessions will be kept strictly confidential. All information revealed by you in a counseling/therapy session and most information placed in your file is considered “protected health information” by the Health Insurance Portability and Accountability Act (HIPAA). As such, your protected health information cannot be distributed to anyone else without your explicit informed and voluntary written consent or authorization. The exceptions to this are defined below. Use or Disclosure of the following protected health information does not require your consent or authorization:
Uses and disclosures required by law o Such as files subpoenaed by a judge Uses and disclosures about victims/perpetrators of abuse, neglect, or domestic violence o Such as the duty to warn when someone is likely to endanger the lives of themselves or others Uses and disclosures for judicial and administrative proceedings o Should you be claiming malpractice or breech of ethics Uses and disclosures to avert a serious threat to your own health or safety o To obtain a court ordered commitment hearing Uses and disclosures for Worker’s Compensation cases o Basic information obtained related to the case
No Court Agenda In order to maintain confidentiality and preserve good therapeutic relationships between counselor and client, I do not make custody/legal evaluations or testify in court unless specifically subpoenaed by a judge.
Client Rights
As a client, you have the right to be treated with dignity and respect. As a client, you have the right to request a history of all disclosures of your protected information. As a client, you can choose to release any protected health information, but you will be required to sign a Release of Information form detailing exactly to whom and what information you wish to be disclosed. As a client, you have the right to terminate services at any time. As a client, you have the right to register a complaint with the Secretary of Health and Human Services if you feel your rights have been violated.
Acknowledgement of Privacy Practices I have been provided the Notice of Privacy Practices for my review. I understand that this notice is to inform me of my rights in regards to my Protected Health Information and when it can be disclosed and for what purposes.
Signature of Client/Legal Guardian: ___________________________________ Date: ________________________
864.760.3150
[email protected]
Health Insurance Portability and Accountability Act (HIPAA) Confidentialty Information you share during your sessions will be kept strictly confidential. All information revealed by you in a counseling/therapy session and most information placed in your file is considered “protected health information” by the Health Insurance Portability and Accountability Act (HIPAA). As such, your protected health information cannot be distributed to anyone else without your explicit informed and voluntary written consent or authorization. The exceptions to this are defined below. Use or Disclosure of the following protected health information does not require your consent or authorization:
Uses and disclosures required by law o Such as files subpoenaed by a judge Uses and disclosures about victims/perpetrators of abuse, neglect, or domestic violence o Such as the duty to warn when someone is likely to endanger the lives of themselves or others Uses and disclosures for judicial and administrative proceedings o Should you be claiming malpractice or breech of ethics Uses and disclosures to avert a serious threat to your own health or safety o To obtain a court ordered commitment hearing Uses and disclosures for Worker’s Compensation cases o Basic information obtained related to the case
No Court Agenda In order to maintain confidentiality and preserve good therapeutic relationships between counselor and client, I do not make custody/legal evaluations or testify in court unless specifically subpoenaed by a judge.
Client Rights
As a client, you have the right to be treated with dignity and respect. As a client, you have the right to request a history of all disclosures of your protected information. As a client, you can choose to release any protected health information, but you will be required to sign a Release of Information form detailing exactly to whom and what information you wish to be disclosed. As a client, you have the right to terminate services at any time. As a client, you have the right to register a complaint with the Secretary of Health and Human Services if you feel your rights have been violated.
Acknowledgement of Privacy Practices I have been provided the Notice of Privacy Practices for my review. I understand that this notice is to inform me of my rights in regards to my Protected Health Information and when it can be disclosed and for what purposes.
Signature of Client/Legal Guardian: ___________________________________ Date: ________________________
