As a professional I will use my best knowledge and skills to help you with your problems and concerns. This includes following the rules, standards and codes of ethics of my profession and the professional organizations of which I am a member.
I treat with great care any information you share with me.
We will discuss fully the limits of confidentiality before proceeding with our first session.
*I ask that you read the following Notification of Privacy Practices prior to our first meeting.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION’ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
My commitment to your privacy
My practice is dedicated to maintaining the privacy of your personal health information. We are required also by law to do this. These laws are complicated, but we must provide you with important information.
I will use the information about your health which I get from you or from others mainly to provide you with treatment, to arrange payment for my services or for some other business activities which are called, in the law, health care operations. After you have read this NPP I will ask you to sign a Consent Form to let me use and share your information. If you do not consent and sign this form, I cannot treat you.
If I or you want to use or disclose (send, share, release) your information for any other purposes I will discuss this with you and ask you to sign an Authorization to allow this.
Of course I will keep your health information private but there are some times when the laws require us to use or share it such as:
1. When there is a serious threat to your health and safety or the health and safety of another individual or the public. I will only share information with a person or organization who is able to help prevent or reduce the threat.
2. Some lawsuits and legal or court proceedings.
3. If a law enforcement official requires to do so.
4. For Workers Compensation and similar benefit programs.
Your rights regarding your health information
1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place. For example, you can ask me to call you at home, and not at work to schedule or cancel an appointment. I will try our best to do as you ask.
2. You have the right to ask me to limit what we tell certain individuals involved in your care or the payment for your care, such as family members and friends. While I don’t have to agree to your request, if, we do agree, we will keep our agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you.
3. You have the right to look at the health information I have about you such as your medical and billing records.You can even get a copy of these records but I may charge you.
4. If you believe the information in your records is incorrect or incomplete, you can ask me to make some kinds of changes (called amending) to your health information. You have to make this request in writing and send it to me. You must tell us the reasons you want to make the changes.
5. You have the right to a copy of this notice. If I change this NPP I will post it in the waiting room and you can always get a copy of the NPP from me.
6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care I provide to you in any way.
If you have any questions regarding this notice or my health information privacy policies, please contact me by phone at 770-338-7463, or by email.
The effective date of this notice is April 14, 2003.