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SAMPLE
(Linked)
[ Items in red below are linked
to the related laws and regulations in Virginia.]
Clinicians in other states must tailor those sections to match their
own state laws
and their own personal policies and intentions about
confidentiality/disclosure.
LETTERHEAD "Notice
of Privacy Practices"
+ Consent to Accept This Office's Confidentiality
Policies
THIS NOTICE
INVOLVES YOUR PRIVACY RIGHTS
AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE
DISCLOSED,
AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION.
PLEASE REVIEW
IT CAREFULLY. I.
Confidentiality:
Uses and Disclosures of Information Requiring Your Authorization
or Consent As
a rule, I will disclose no information about you, or the fact that you are my
patient, without your written consent. My
formal Mental Health Record describes the services provided to you and contains
the dates of our sessions, your diagnosis, functional status, symptoms, prognosis
and progress, and any psychological testing reports. Health care providers are
legally allowed to use or disclose records or information for treatment, payment,
and health care operations purposes. However, I do not routinely disclose information
in such circumstances, so I will require your permission in advance, either
through your consent at the onset of our relationship (by signing the attached
general consent form), or through your written authorization at the time the
need for disclosure arises. You may revoke your permission, in writing, at
any time, by contacting me.
II.
"Limits of Confidentiality:"
Possible Uses and Disclosures of Mental
Health Records without
Consent or Authorization There
are some important exceptions to this rule of confidentiality - some exceptions
created voluntarily by my own choice, [some because of policies in this office/agency],
and some required by law. If you wish to receive mental health services from me,
you must sign the attached form indicating that you understand and consent to
accept my policies about confidentiality and its limits. We will discuss these
issues now, but you may reopen the conversation at any time during our work together.
I
may use or disclose records or other information about you without your consent
or authorization in the following circumstances, either by policy, or because
legally required:
· Emergency If you are involved in in a life-threatening emergency
and I cannot ask your permission, I will share information if I believe you would
have wanted me to do so, or if I believe it will be helpful to you.
· Child
Abuse Reporting: If I have reason to suspect that a child is abused or
neglected, I am required by Virginia law to report the matter immediately to the
Virginia Department of Social Services (
§ 63.2-1509
).
· Adult
Abuse Reporting: If I have reason to suspect that an elderly or incapacitated
adult is abused, neglected or exploited, I am required by Virginia law to immediately
make a report and provide relevant information to the Virginia Department of Welfare
or Social Services (
§ 63.2-1606
).
· Health Oversight:
[For licensed psychologists and social workers:] Virginia law requires
that I report misconduct by a mental health care provider of my own profession.
By policy, I also reserve the right to report misconduct by health care providers
of other professions. [For Counselors: Virginia law requires that licensed
counselors report misconduct by any mental health care provider.] ( See
licensing board regulations ). By law, if you describe unprofessional conduct
by another mental health provider of any profession, I am required to explain
to you how to make a report to the licensing board ( §
54.1-2400.4
). If you are yourself a health care provider, I am required by law to report
to your licensing board if I believe your condition places the public at risk
( § 54.1-2400.7
). Virginia Licensing
Boards have the power, when necessary, to subpoena relevant records for investigating
a complaint of provider incompetence or misconduct.
· Court Proceedings:
If you are involved in a court preceding and a request is made for information
about your diagnosis and treatment and the records thereof, such information is
privileged under state law, and I will not release information unless you provide
written authorization or a judge issues a court order (§
8.01-399;
§ 8.01-400.2
). If I receive a subpoena
for records or testimony, I will notify you so that you (or your attorney, or
I ) can file a motion
to quash (block) the subpoena and can give reasons why I think your records
should be protected from disclosure [Clinician: for reasons, see paragraph
H-6 in § 32.1-127.1:03).
However, while awaiting the judge's decision, I am required to place said records
in a sealed envelope and provide them to the Clerk of Court. In Virginia, parents'
records may not be used as evidence (i.e., are privileged) in child custody cases
( § 20-124.3:1
), including records
about parents held by a child's therapist ( see Schwartz
case ); but a child's records
do not have that same protection. NOTE: In civil court cases, therapy information
or records are not protected by patient-therapist privilege in child abuse cases,
in cases in which your mental health is an issue, or in any case in which the
judge deems the information to be "necessary for the proper administration of
justice." In criminal cases, Virginia has no statute granting therapist-patient
privilege, although records can sometimes be protected on another basis. Protections
of privilege may not apply if I do an evaluation for a third party or where the
evaluation is court- ordered. You will be informed in advance if this is the case.
·
Serious Threat to Health or Safety: Under Virginia law, if I am engaged in
my professional duties and you communicate to me a specific and immediate threat
to cause serious bodily injury or death, to an identified or to an identifiable
person, and I believe you have the intent and ability to carry out that threat
immediately or imminently, I am legally required to take steps to protect third
parties ( § 54.1-2400.1
). These precautions may include
1) warning the potential victim(s), or the parent or guardian of the potential
victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking
your hospitalization. By my own policy, I may also use and disclose medical information
about you when necessary to prevent an immediate, serious threat to your own health
and safety.
· Workers Compensation: If you file a worker's compensation
claim, I am required by law, upon request, to submit your relevant mental health
information to you, your employer, the insurer, or a certified rehabilitation
provider.
· Records of Minors: Virginia has a number of laws that limit
the confidentiality of the records of minors. For example, parents, regardless
of custody, may not be denied access to their child's records (
§ 20-124.6
); and CSB evaluators in civil commitment cases have legal access to therapy records
without notification or consent of parents or child ( §
16.1-342
).
Other circumstances may also apply, and we will discuss these in detail if I provide
services to minors. [Clinician: On this site, also see discussion of minors'
confidentiality rights under HIPAA and Virginia law; discussion of how custody
agreements might affect divorced parents' right to seek mental health services
for their child; and a Sample Adolescent
Consent Form, to be signed by minor and parent]
Other uses and disclosures of information not covered by this notice or by the
laws that apply to me will be made only with your written permission. III.
Patient's Rights and Provider's Duties:
· Right to Request Restrictions-You have the right to request restrictions
on certain uses and disclosures of protected health information about you. You
also have the right to request a limit on the medical information I disclose about
you to someone who is involved in your care or the payment for your care. If you
ask me to disclose information to another party, you may request that I limit
the information I disclose. However, I am not required to agree to a restriction
you request. To request restrictions, you must make your request in writing, and
tell me: 1) what information you want to limit; 2) whether you want to limit my
use, disclosure or both; and 3) to whom you want the limits to apply.
·
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 me. Upon your request, I
will send your bills to another address. You may also request that I contact you
only at work, or that I do not leave voice mail messages.) To request alternative
communication, you must make your request in writing, specifying how or where
you wish to be contacted.
· Right to an Accounting of Disclosures -
You generally have the right to receive an accounting of disclosures of PHI for
which you have neither provided consent nor authorization (as described in section
III of this Notice). On your written request, I will discuss with you the details
of the accounting process
. Right to Inspect and Copy - In most cases,
you have the right to inspect and copy your medical and billing records. To do
this, you must submit your request in writing. If you request a copy of the information,
I may charge a fee for costs of copying and mailing. I may deny your request to
inspect and copy in some circumstances. I may refuse to provide you access to
certain psychotherapy notes or to information compiled in reasonable anticipation
of, or use in, a civil criminal, or administrative proceeding.
· Right
to Amend - If you feel that protected health information I have about you
is incorrect or incomplete, you may ask me to amend the information. To request
an amendment, your request must be made in writing, and submitted dot me. In addition,
you must provide a reason that supports s your request. I may deny your request
if you ask me to amend information that: 1) was not created by me; I will add
your request to the information record; 2) is not part of the medical information
kept by me; 3) is not part of the information which you would be permitted to
inspect and copy; 4) is accurate and complete.
· Right to a copy of this
notice - You have the right to a paper copy of this notice. You may ask me
to give you a copy of this notice at any time. Changes to this notice: I reserve
the right to change my policies and/or to change this notice, and to make the
changed notice effective for medical information I already have about you as well
as any information I receive in the future. The notice will contain the effective
date . A new copy will be given to you or posted in the waiting room. I will have
copies of the current notice available on request. Complaints:
If you believe your privacy rights have been violated, you may file a complaint.
To do this, you must submit your request in writing to my office. You may also
send a written complaint to the U.S. Department of Health and Human Services.
EFFECTIVE
DATE: _________________ ===========================================================================
LETTERHEAD Patient's
Acknowledgement of
Receipt of Notice of Privacy Practices Please
sign, print your name, and date this acknowledgement form.
I have been provided a copy of [Dr. Fisher's] Notice of Privacy Practices."
We
have discussed these policies, and I understand that I may ask questions about
them at any time in the future. I
consent to accept these policies as a condition of receiving mental health services.
Signature:
___________________________________________________________________ Printed
Name: ___________________________________________________________________ Date:
______________________ Return
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