Notice of Privacy Practices

You have certain rights and responsibilities when consulting a mental health professional. Some of these are listed below:

2. The Right to Choose the Best Treatment Provider

There are many different professionals who offer mental health services, and many different ways of working with human problems. No professional can offer the best treatment for every type of problem. It is your right and responsibility to choose the one that best fits your needs. If we are not a good match, I encourage you to talk to me about it and we will either revise your treatment plan or refer you to someone who may be better suited to your needs.

3. The Right to Privacy

This issue is dealt with extensively in the following Privacy Notice. The law guarantees confidentiality between counselors and their clients. This means that whatever you tell me is private, and I make every attempt to protect information about you from possible misuse. In many cases, your written permission is required before I can release records. However, there are a few exceptions not covered in the attached privacy notice about which you should know:

If you choose to use insurance to cover your treatment costs, you will need to sign a release giving your insurance company the right to know certain things about you. This information includes a diagnosis, type of treatment, dates, and sometimes a justification for treatment. While most insurance companies keep medical information confidential, I cannot guarantee confidentiality once information leaves this office. If the insurance company asks for more detailed information than usual, I will speak to you about it and let you decide what you want them to know. However, if you choose not to provide them with information, you may be assuming financial responsibility for treatment costs yourself.

You need to be aware that if you decide to sue someone for a personal injury that is the focus of your treatment, you may be signing away your right to confidentiality. The defendant may be able to gain access to your treatment records to help in their defense.

I make every effort to resolve overdue accounts with friendly reminders and phone calls. When this fails, I refer delinquent accounts to a professional collection agency. While they can’t see treatment records, they will need to know a client’s name, dates of service, and amount due.

IMPORTANT PRIVACY NOTICE: THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION: I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

II. Uses and Disclosures for Treatment, Payment, and Health Care Operations with Consent

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

“PHI” refers to information in your health record that could identify you.

“Treatment” is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another mental health professional.

“Payment” is when I obtain reimbursement for your health care. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

“Health Care Operations” are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

“Use” applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

“Disclosure” applies to activities outside of my office such as releasing, transferring, or providing access to information about you to other parties.

III. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures.

If I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your Clinical Record and/or Therapy Notes. “Therapy Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session. I keep these separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or therapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have already acted in reliance on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

IV. Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

Abuse of children or vulnerable adults: If I have reason to believe that a child, elderly person, or disabled person is being abused, or in imminent danger of abuse (including being exposed to domestic violence), I am legally and ethically obligated to report this to the appropriate social services to ensure that everyone is kept safe.

Duty to warn and protect: If I have reason to believe that you are at risk of making a serious and imminent attempt to inflict serious bodily harm or kill yourself or someone else, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, and seeking hospitalization for the client. If the client threatens to harm himself/herself, I may also contact family members or others who can help provide protection.

Court orders: For judicial or administrative proceedings in response to a valid court order, summons, subpoena, or warrant.

Legal actions: If you initiate a legal action or ethical charge against me.

Minors/Guardianship: Parents or legal guardians of minor clients have the right to access the client’s records.

V. Patient’s Rights:

Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.

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 can ask that I send bills to an address other than your home).

Right to Inspect and Copy – You have the right to inspect or obtain a copy of PHI and therapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. There may be a fee for copying this information. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.

Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

Right to an Accounting – 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 request, I will discuss with you the details of the accounting process.

Right to a Paper Copy – You have the right to obtain a paper copy of this notice from me upon request, even if you have agreed to receive this notice electronically.

I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. However, unless I notify you of such changes, I am required to abide by the terms currently in effect.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice is effective September 1, 2024. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by giving or mailing you a revised copy, and/or posting it on the following website: www.yoeleverett.com.

Acknowledgement of Receipt of Informed Consent for Treatment & Notice of Privacy Practices

By agreeing to this form, you are acknowledging that you have received a copy of the Informed Consent for Treatment & Notice of Privacy Practices.