NOTICE OF PRIVACY PRACTICES

 

THIS NOTICE DESCRIBES HOW CLIENT INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS

INFORMATION.  PLEASE REVIEW IT CAREFULLY.

 

Our commitment here at Pathways Christian Counseling is to serve our clients with professionalism and caring, being sure at all times to protect the privacy and security of all Protected Health Information.

 

During the course of serving your interests it may be necessary to share information with other Health Care Providers or Licensed Supervisors.  The following are examples of instances where information may be shared:

 

In privileged communication, the client is protected from having communications revealed without their explicit permission to do so.  For example, we will not release psychological reports about you to schools, agencies, physicians, etc., without your written approval.  There are exceptions to this statement on confidentiality, which are outlined below.

 

· The therapist may discuss your case with a supervisor as a means of determining the most appropriate diagnosis or treatment plan.

· If your fees are paid by a third party (such as an insurance company), certain details of your treatment (e.g. dates, treatment and diagnosis) must be revealed to obtain reimbursement.  Many insurance companies now allow you to file claims directly with them so that your employer will not see this information.

· If a client reveals information that indicates a clear danger of injury to him/herself or to others, the therapist will need to contact appropriate authorities or family members.

· By Ohio law, we have a legal responsibility to notify appropriate social agencies of any suspicion or knowledge of the physical or sexual abuse or neglect of a child, a disabled person, or an elderly person.

 

We here at Pathways Christian Counseling are committed to obeying all Federal, State and Local laws and regulations regarding Privacy Practices.  If any other uses or disclosures than the ones listed above are needed, information will only be released with the written authorization of the individual in question.  This written authorization maybe revoked at any time by the individual, as provided for by law.

 

If you have any questions or comments regarding your Protected Health Information, feel free to contact our Compliance Officer.

 

I have read and understand the above Notice of Privacy Practices.

 

 

Signed _________________________ Printed Name _______________________ Date ______

                    (Patient/Guardian)                                              (Print Name)

 

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