This notice describes how information about you may be used and disclosed and how you can get access to it.
Your medical records are used to provide counseling, and bill and receive payments. Examples of these operations include but are not limited to review of counseling records to ensure appropriate treatment, electronic or mail delivery of billing for counseling to you or other authorized payers, appointment reminder emails, and records review to ensure completeness and quality of care. Use and disclosure of medical records is limited to the internal uses outlined above except required by law or authorized by the patient or legal guardian.
Federal and State laws require abuse, neglect, domestic violence and threats to be reported to social services or other protective agencies. If such reports are made they will be disclosed to you or your legal representative unless disclosure increases risk of further harm.
Disclosed information will be limited to the minimum necessary. You may request an account for any uses or disclosures other than those described in Sections 1 and Sections 2.
You, or your legal representative, may request your records to be disclosed to yourself or any other entity. Your request must be made in writing, clearly identify the person authorized to request the release, specify the information you want disclosed, the name and address of the entity you want the information released to, purpose and the expiration date of the authorization. Any authorization provided may be revoked in writing at anytime. Counseling notes are part of your medical records. We have 30 days to respond to a disclosure request and 60 days if the records is stored off site.
A request for disclosure may be denied under the following circumstances: disclosure would likely endanger the life or physical safety of you or another person, requested information references other persons, except another healthcare provider, or if release to a legal representative would likely result in harm.
This agreement may be modified or amended as required by law or in the course of health care operations.