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Informed Consent for Assessment & Treatment

Client Registration

HIPAA Client Rights

HIPAA Notice of Privacy Practices

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Right to request how we contact you

It is my normal practice to communicate with you at your home address and daytime phone number you gave me when you scheduled your appointment, about health matters, such as appointment reminders etc.  Sometimes I may leave messages on your voicemail.  You have the right to request that my office communicate with you in a different way. 


Right to release your medical records

You may consent in writing to release your records to others.  You have the right to revoke this authorization, in writing, at any time. However, a revocation is not valid to the extent that I acted in reliance on such authorization


Right to inspect and copy your medical and billing records.

You have the right to inspect and obtain a copy of your information contained in my medical records. You may request access to your billing or health information.  Under limited circumstances, I may deny your request to inspect and copy records. If you ask for a copy of any information, I may charge a reasonable fee for the costs of copying, mailing and supplies.


Right to add information or amend your medical records.

If you feel that information contained in your medical record is incorrect or incomplete, you may ask me to add information to amend the record.  I will make a decision on your request with 60 days, or some cases within 90 days.  Under certain circumstance, I may deny your request to add or amend information.  If I deny your request, you have a right to file a statement that you disagree. Your statement and my response will be added to your record.  I will require you to submit your request in writing and to provide an explanation concerning the reason for your request.


Right to request restrictions on uses and disclosures of your health information.

You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing. However, I am not required to agree to such a request.


Right to complain.

If you believe your privacy rights have been violated, please contact me personally, and discuss your concerns.  If you are not satisfied with the outcome, you may file a written complaint with the U.S. Department of Health and Human Services. An individual will not be retaliated against for filing such a complaint.


Right to receive changes in policy.

You have the right to receive any future policy changes secondary to changes in state and federal laws..


Depression  Scre