Professional Disclosure Information/HIPAA

Whiting and Associates, LLC

 

PROFESSIONAL DISCLOSURE INFORMATION

HIPAA

 

Your signature below indicates that you have read this agreement and agree to its terms and serves as acknowledgement that you have received the HIPAA notice form.  Not abiding by these policies may lead to termination of our work together and/or referral to another professional.

I understand and agree that this is an electronic form of my signature and is legal and binding as such.
I understand and agree that this is an electronic form of my signature and is legal and binding as such.

CLIENT RIGHTS

 

 

YOU HAVE THE RIGHT

  • TO BE TREATED WITH CONSIDERATION AND RESPECT
  • TO EXPECT QUALITY SERVICES PROVIDED BY CONCERNED, COMPETENT STAFF
  • TO A CLEAR STATEMENT OF PURPOSES, GOALS, TECHNIQUES, RULES OR PROCEDURE AND LIMITATIONS AS WELL AS POTENTIAL DANGERS OF THE SERVICES TO BE PERFORMED PLUS ALL OTHER INFORMATION RELATED TO OR LIKELY TO EFFECT THE ON-GOING CONSELING RELATIONSHIP.
  • TO OBTAIN INFORMATION ABOUT THE CASE RECORD AND TO HAVE THIS INFORMATION EXPLAINED CLEARLY AND DIRECTLY
  • TO FULL KNOWLEDGEABLE AND RESPONSIBLE PARTICIPATION IN THE ON-GOING TREATMENT PLAN TO MAXIMUM FEASIBLE EXTENT
  • TO EXPECT COMPLETE CONFIDENTIALITY AND THAT NO INFORMATION WILL BE RELEASED WITHOUT WRITTEN CONSENT
  • TO SEE AND DISCUSS CHARGES AND PAYMENT RECORDS
  • TO REFUSE ANY RECOMMENDED SERVICES AND BE ADVISED OF THE CONSEQUENCES OF THIS ACTION
I understand and agree that this is an electronic form of my initials and is legal and binding as such.

CONFIDENTIALITY OF INFORMATION

 

LAWS THUS INSURING YOUR RIGHT TO PRIVACY PROTECT MATTERS DISCUSSED WITH YOUR THERAPIST.  IN MOST CASES, YOUR THERAPIST IS PROHIBITED FROM DISCLOSING INFORMATION ABOUT YOUR CARE WITHOUT YOUR WRITTEN CONSENT AND THEN ONLY TO THE EXTENT YOU. I AUTHORIZE LIMITS TO CONFIDENTIALITY INCLUDING OFFICE STAFF, PEER SUPERVISION AND ACCOUNT FOR FINANCIAL RECORDS.

 

  • CASES WHERE INFORMATION MAY BE DISCLOSED WITHOUT CONSENT
  • WHEN CHILD ABUSE IS KNOWN OR SUSPECTED (REPORTING REQUIRED BY LAW)
  • WHEN THE ABUSE OF AN ELDERLY OR DEPENDENT PERSON IS KNOWN OR SUSPECTED (REPORTING REQUIRED BY LAW)
  • IF YOU COMMIT A CRIME AGAINST A STAFF MEMBER OR ANOTHER PERSON ON THE PREMISES
  • IF YOU BRING CHARGES AGAINST YOUR CLINICIAN
  • IF THERE IS A SITUATION THAT IS POTENTIALLY LIFE THREATENING
  • WHEN RECORDS ARE SUBPOENED BY THE COURT
I understand and agree that this is an electronic form of my initials and is legal and binding as such.

SECURITY OF RECORDS

 

YOUR TREATMENT RECORD AND RELATED FINANCIAL RECORDS ARE KEPT IN A LOCKED FILE CABINENT IN AN OFFICE OR OTHER AREA NOT ACESSIBLE TO THE PUBLIC.  RECORDS WILL NOT BE COPIED OR OTHERWISE MADE AVAILABLE TO OTHERS WITHOUT A SIGNED AUTHORIZATION TO RELEASE INFORMATION.

 

SPECIAL RULES RELATING TO THE RELEASE OF TREATMENT RECORDS CONTAINIG INFORMATION REGARDING DRUG AND ALCOHOL ABUSE

CFR42, PART 2 PROHIBITS DISCLOSURE OF SUCH INFORMATION WITHOUT WRITTEN CONSENT OF THE CLIENT AND ONLY TO THE EXTENT SPECIFICALLY AUTHORIZED.  THIS INFORMATION CANNOT BE REDISCLOSED TO ANOTHER SOURCE WITHOUT WRITTEN CONSENT.  A GENERAL RELEASE FOR MEDICAL OR OTHER INFORMATION IS NOT SUFFICENT.  USE OF INFORMATION IN RECORDS FOR CRIMINAL INVESTIGATION AND PROSECUTION IS PROHIBITED.

I understand and agree that this is an electronic form of my signature and is legal and binding as such.

RETENTION OF RECORDS

 

TREATMENT RECORDS ARE RETAINED FOR A PERIOD OF SEVEN (7) YEARS FOLLOWING THE TERMINATION OF TREATMENT FOR ADULTS AND UNTIL AGES TWENTY FOUR (24) IN THE CASE OF MINORS.  AT THE END OF THAT PERIOD, THE RECORDS ARE DESTROYED IN A MANNER THAT ASSURES THE CONFIDENTIALITY OF THE INFORMATION UNLESS THE CLIENT REQUESTS OTHERWISE, IN WRITING, PRIOR TO THE DESTRUCTION OF THE RECORDS.

 

  • INFORMATION REGARDING PSYCHOTHERAPY

PSYCHOTHERAPY MAY INVOLVE REMEMBERING UNPLEASANT EVENTS AND CAN AROUSE INTENSE EMOTIONS OF FEAR AND ANGER.FEELING OF ANXIETY, DEPRESSION, FRUSTRATION, LONELINESS, OR HELPLESSNESS MAY BE EXPERIENCED.OF COURSE, FELELING OF RELIEF, ENERGY, POWER, SELF-ACCEPTANCE AND WELL-BEING MAY OCCUR.

  • PSYCHOTHERAPY IS NOT ALWAYS EFFECTIVE AND MAY, IN SOME CASES, RESULT INDETERIORATION RATHER THAN INPROVEMENT OF A CLIENT’S PSYCHOLOGICAL FUNCTION.  PSYCHOTHERAPY HAS BEEN SHOWN TO BE EFFECTIVE IN ABOUT 75% OF CASES.
  • THERE ARE NUMEROUS FORMS OF PSYCHOTHERAPY, WHICH VARY, NOT ONLY IN UNDERLYING THEORY AND METHODS EMPLOYED, BUT ALSO IN TERMS OF TIME COMMITMENT AND COST.  WE WILL ATTEMPT TO PROVIDE TREATMENT PLANS THAT ARE REALISTIC IN BOTH AREAS.
  • CURRENT RESEARCH HAS FAILED TO DEMONSTRATE THAT ANY ONE FORM OF PSYCHOTHERAPY IS NECESSARILY MORE EFFECTIVE THAN ANY OTHER.
  • DEPENDING UPON A CLIENT’S CONDITION, THERE MAY BE AVAILABLE ALTERNATIVES TO PSYCHOTHERAPY, SUCH AS MEDICATION OR BEHAVIOR MODIFICATION.  WE WILL MAKE THESE RECOMMENDATIONS IF THEY ARE APPROPRIATE, BASED UPON OUR ASSESSMENT.
I understand and agree that this is an electronic form of my initials and is legal and binding as such.

CONSENT TO TREAT

 

I HEREBY GIVE MY CONSENT TO MY THERAPIST TO PROVIDE ASSESSMENT AND THERAPEUTIC SERVICES TO ME/MY CHILD, WITHIN THE SCOPE OF HIS/HER LICENSE.  I UNDERSTAND MY THERAPIST WILL WORK WITH ME TO DEVELOP A TREATMENT PLAN AND TREATMENT WILL BE FORMULATED TO RESOLVE MY PROBLEM(S) AS QUICKLY AS POSSIBLE.  I AGREE TO COOPERATE WITH MY THERAPIST IN THE TREATMENT PROCESS, TO CARRY OUT THERAPEUTIC HOMEWORK ASSIGNMENTS AND TO TAKE ANY MEDICATIONIS PRESCRIBED AS PART OF MY TREATMENT IN THE MANNER DIRE TED BY THE PRESCRIBING, PHYSICIAN.  I FURTHER AGREE TO KEEP MY SCHEDULED APPOINTMENTS AND UNDERSTAND THAT FAILURE TO DO SO MORE THAN TWO (2) TIMES MAY RESULT IN MY CARE BEING TERMINATED.

 

BY MY SIGNING BELOW, I AGREE TO THE PAYMENT ARRANGEMENTS AS SET FORTH AFFIRM THAT ALL MY QUIESIONS HAVE BEEN SATISFACTORILY ANSWERED, AND GIVE INFORMED CONSENT TO MY/MY CHILDS TREATMENT.  I UNDERSTAND THAT I WILL BE FURNISHED A COPY OF THIS CONSENT WHENEVER I MAY REQUEST IT.

(Signature of Responsible Party) I understand and agree that this is an electronic form of my signature and is legal and binding as such.
(Signature of Patient) I understand and agree that this is an electronic form of my signature and is legal and binding as such.
I agree and understand that this is an electronic form of my signature and is legal and binding as such. Any misrepresentation of witness signature constitutes fraud and will be subject to prosecution.
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