Notice of Assessment and Counseling Services’ Policies and Practices
to Protect the Privacy of Your Health Information 
(Revised 7/22/2010)
This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.  

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
•	"PHI' refers to information in your health record that could identify your "Treatment, Payment and Health Care Operations"
- Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An    example of treatment would be when we consult with another health care provider, such as your family physician or another Therapist. Another example would be when we release your treatment plan to your insurance company and/or to your primary care physician.
- Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
- Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
•	"Use" applies only to activities within our [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
•	"Disclosure" applies to activities outside of our [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we asked for information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your Psychotherapy Notes. "Psychotherapy Notes" are notes we have made about your conversation during a private, group, joint, or family counseling session, which we 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 or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (I) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances:
•	Child Abuse - If we have reasonable cause to believe that a child has been abused, we must report that belief to the appropriate authority.
•	  Adult and Domestic Abuse - If we have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, we must report that belief to the appropriate authority.
•	   Health Oversight Activities - If we are the subject of an inquiry by the Georgia Board of Psychological Examiners, we may be required to disclose protected health information regarding you in proceedings before the Board.
•	Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made about the professional services we provided you or the records thereof, such information is privileged under state law, and we will not release information without your written consent 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 informed in advance if this is the case.
Please see other side and sign

•	Serious Threat to Health or Safety - If we determine, or pursuant to the standards of my profession should determine, that you present a serious danger of violence to yourself or another, we may disclose information in order to provide protection against such danger for you or the intended victim.

•	Worker's Compensation - we may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs, established by law, that provide benefits for work related injuries or illness without regard to fault.

IV. Patient's Rights and Therapist's Duties 
Patient's Rights: 
•	Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you 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 and at alternative locations. (For example, you may not want a family member to know that you are seeing therapists. On your request, we will send your bills to another address.)
•	Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI in your mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process. Your therapist may also deny access to your Psychotherapy Notes.
•	Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
•	Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI. On your request, we 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 us upon request, even if you have agreed to receive the notice electronically.

Therapist's Duties: 
•	We are 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.
•	We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
* If we revise these policies and procedures, we will notify you at your next session.

V. Complaints
If you are concerned that your therapist has violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Paula Sroka at Assessment and Counseling Services You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Ms. Sroka can provide you with the appropriate address upon request.

VI. Cancellation Policy
In the event of a life threatening emergency, you will not be charged for session cancellation. Cancellations for any other reason, that are not received by center staff at least 24 hours prior to the scheduled session, will be billed at the usual hourly rate of $120.00. Your insurance company will not pay for missed appointments.

Client Name (printed): _____________________________________________________________________________________

Signature of Client or Parent/Guardian: _______________________________________________________________________

Date: _____________________________________________   Witness: _____________________________________________