Patient Policy form

HIPAA PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMAITON. PLEASE REVIEW IT CAREFULLY. When you sign this document, it is a binding agreement. You may revoke or restrict portions of this agreement in writing at any time as provided below under “ADDITIONAL RIGHTS.” That revocation or restriction is binding on us unless we have taken action in reliance on it or if your authorization was obtained as a condition of obtaining insurance coverage or other law provides you with a right to contest a claim and you have not satisfied any financial obligations you have incurred.

PROFESSIONAL RECORDS

We are required to keep appropriate records of the psychological and psychiatric services that we provide. Your records are maintained in a secure electronic health record (EHR) that is HIPAA compliant and accredited. Although mental health treatment often includes discussions of sensitive and private information, normally brief records are kept noting that you have been here, what was done in session, and a mention of the topics discussed. You have the right to request that a copy of your file be made available to any other health care provider or for yourself at your written request.

PSYCHOTHERAPY NOTES

Psychotherapy notes require specific authorization to be released except for use of the notes for treatment, to defend PTP in a legal action or other proceeding brought by you and other specific legally permitted exceptions. The term "psychotherapy notes" means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint or family counseling session and that are separated from the rest of the individual's record. No one except PTP staff or a contracted clinical consultant covered by a business associate agreement will view or read of a session unless you give permission.

THIRD PARTY RELEASE

Once medical records are released to a third party, they may no longer be protected by state and federal privacy laws.

CONFIDENTIALITY

The confidentiality of all communications between a patient and a mental health provider is generally protected by law and we cannot and will not tell anyone else what you have discussed or even that you are in treatment with us without your written permission, unless otherwise required by law. In most situations, we only release information about your treatment to others with your written authorization. You, on the other hand, may request that information is shared with whomever you choose, and you may revoke that permission in writing at any time, except that consent may not be revoked in situations in which we are required by law to disclose PHI. There are several exceptions in which we are legally bound to take action that requires revealing some information about a patient's treatment and other situations in which it is permitted to use and disclose PHI for treatment purposes. The situations in which we are permitted or required, to reveal PHI include, but are not limited, to the following:

• 1. If there is good reason to believe you are threatening serious bodily harm to yourself, or if we believe a patient is threatening serious bodily harm to another, we may be required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a patient threatens harm to themselves or another, we may be required to seek hospitalization for the patient, or to contact family members or others who can provide protection.
• 2. To report suspected, or evidence of, abuse or neglect of children, disabled persons and vulnerable adults. In such a situation, we are required by law to file a report with the appropriate state agency.
• 3. In response to a subpoena or other court order or where otherwise required by
• 4. In situations in which it is appropriate to report to the National Instant Criminal Background Check System.
• 5. To the extent necessary, to collect payment and to make a claim on a delinquent account.
• 6. To the extent necessary for emergency medical care to be
• 7. To discuss your care within our clinic’s treatment team, or to seek professional consultation with colleagues outside this clinic, PHI is disclosed for multidisciplinary team case consultations. Those professionals consulting on your case are also required to keep the information
• 8. For health care & clinic operations, e.g., outcomes evaluation or quality assessment activities.

PATIENT RIGHTS

You have the following additional rights regarding PHI:

• The right to receive confidential communications of PHI and to make a written request to receive communications of PHI by alternative means or at alternative locations
• The right to inspect and receive a paper or electronic copy of PHI except for psychotherapy notes and information complied in reasonable anticipation of, or for use in a civil, criminal or administrative action or proceeding and other specific instances provided by law, such as if your PHI was obtained from someone other than your health care provider under a promise of confidentiality and access to the PHI would be reasonably likely to reveal the source of the information.
• The right to request amendment of PHI in writing in certain circumstances as permitted by law.
• The right to receive an accounting of disclosures of PHI during the six years preceding your request, except as to those not required to be disclosed by law.
• The right to request a paper copy of this notice from PTP, even if you have already agreed to receive notice electronically.
• The right to be notified if there has been a breach involving your PHI.
• The right to revoke consent to release of your medical records. If you want to revoke consent, it must be in writing and sent to the PTP. Your revocation does not apply to records that have already been released.

EXCEPTIONS

You have the right to view your PHI, with a few exceptions:

• If a doctor or licensed provider believes that it will be harmful to you or others.
• Information compiled in anticipation of, or for use in, a civil, criminal or administrative action or proceeding.

NOTICE

• PTP is required by law to maintain the privacy of PHI and to provide individuals with notice of its legal duties and privacy practices with respect to that PHI.
• PTP is required to abide by the terms of the notice currently in effect.
• PTP reserves the right to change the terms of this notice. The new notice provisions will be effective for all PHI that PTP maintains.
• Any revisions to the Notice will be provided to to you at your next session, via the agency website, or by having copies available at clinic sites.

FILING A COMPLAINT

If you believe your privacy rights have been violated, you may file a complaint with Psychotherapy Partners or with the Department of Health and Human Services Office of Civil Rights (or both), without fear of retaliation by Psychotherapy Partners. For questions or complaints about data privacy or client privacy rights, you may contact your clinician. A complaint to the Office of Civil Rights may be filed in writing through fax, email, OCR Complaint Portal or by mail at: Office for Civil Rights, Regional Manager Customer Response Center: 800-368-1019 U.S. Department of Health and Human Services Fax: 202-619-3818 233 N. Michigan Ave., Suite 240 Email: ocrmail@hhs.gov Chicago, IL 60601

ELECTRONIC COMMUNICATION POLICY

By signing this form, I authorize Psychotherapy Partners, LLC to communicate with me electronically via telephone, email, faxing, the clinic website or internet patient portal, or claims filing sites. These communications will be used for scheduling, and for collecting or sending pertinent clinical, insurance information and claims, billing &/or collections information as is necessary to provide your treatment and or to correspond. I understand that communications via the means as described above, are not always secure. Although it is unlikely, there is a possibility that information you send to us, or that we send to you, may be intercepted, and read by other parties besides the person to whom it is addressed. I understand that by federal law, Psychotherapy Partners, LLC may not use/disclose my healthcare information without my authorization except the information designated in my Patient-Clinician Agreement. My signature on this disclosure indicates that I am giving my permission to engage in the electronic and internet communication described above. I hereby release Psychotherapy Partners, LLC , from any and all liability that may arise from the release of electronic information. I understand that I have the right to revoke this authorization at any time. If I want to revoke this authorization I must do so in writing and address it to Psychotherapy Partners, LLC. I understand that if I revoke this authorization, it will not apply to any information previously released because of this authorization. I understand that I may refuse to sign this authorization. I also understand that Psychotherapy Partners, LLC cannot deny or refuse to provide treatment or billing services if I refuse to sign this authorization. I understand that once the information is disclosed pursuant to this authorization, it is possible that it will no longer be protected by the federal medical privacy law and could be disclosed by the person or agency that receives it.

TELETHERAPY CONSENT

It is our expectation that you will benefit from online therapy as all or part of your psychotherapy, but there is no guarantee. Therapy is conducted using interactive audio and video. Online based services as care may not be appropriate for your needs. If I assess that face to face is more appropriate, I will offer an appointment or provide referrals. Confidentiality: The information disclosed during the course of my therapy is confidential, however, there are legal exceptions both mandatory, and permissible, including a child, elder, and dependent adult abuse; threats of harm to self or others, or if court-ordered. The therapist will take all precautions to ensure online therapy is confidential, but the client is informed that transmission could possibly be disturbed or distorted by technical failures, or interrupted or accessed by unauthorized persons. Appointments and Charges for Services: Patients are responsible for checking with their insurance to verify that Teletherapy Health therapy is covered. Copayment, deductible, and fees not covered by insurance are the client's responsibility and are due at the time of service. Limitations: On-line therapy plays a useful role in addressing mental health issues. It also has inherent limitations in not being physically present. For instance, body language is limited by this format and technical difficulties can have poor timing. Due to these limitations, this method is not recommended when in a state of crisis or when at high risk. When should I seek traditional mental health treatment rather than internet therapy?

• 1. If you are having thoughts of harming yourself and or someone else. Please call 911.
• 2. If you are in an abusive or violent relationship
• 3. If you have been seriously depressed
• 4. If you have serious substance abuse dependence
• 5. If you are a minor (under 18 years old)

Procedures should we encounter technical difficulties or disruptions in service: It is understood that when communicating by internet or other electronic means, disruptions in service or other technical difficulties will likely occur from time to time. Should a disruption occur at a time of crisis, the patient agrees to immediately phone their therapist.

By signing this form:

1. I agree that I reside in the state of Minnesota 2. I have read Patients Policies agreement 3. I have read HIPPA notice 4. I have read Electronic Communication Policy 5. I have read Teletherapy Policy

Your agreed to these policies.

DISCLAIMER :

By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.