This notice describes how medical information about you may be used and disc\osed and how you can get access to this information. Please review it carefully.
In this Privacy Notice, “medical information” and “psychological information” mean the same as “fiealth information.” Health information includes any information that relates to:
Protecting Your Priva :
Counselors must always manage psychological records with great concern for privacy and confidentiality. I am required by law to protect the privacy of your health information. This means that I will not use or disclose your health information without your authorization except in the ways I tell you in this notice. If 1 wish to use or disclose your health information in ways other tfian those stated in this notice, I will ask you for your written authorization. If you give such an authorization, you may revoke it at any time, but I wil[ not be liable for uses or disclosures made before you revoked your authorization.
Although the security of psychological records has continuously been addressed by Counseling Codes of Ethics as well as by State and Federal laws, the rules have been considerably strengthened by the provisions of the Health Insurance Portability and Accountability Act (HIPAA). The following information provides details about the provisions of HIPAA and your rights concerning privacy and your psychological records.
Who will observe these rules?
In my practice, the following individuals are required by HIPAA to comp[y with the privacy rules:
YOUR RIGHTS REGARDING PSYCHOLOGICAL INFORMATION ABOUT YOU:
The Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocke-t You have the right to restrict certain disc losures of PHI to a health plan when you pay out-of-pocker in full for services.
My signature above represents that I have read and understand my rights under HIPAA. Date