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This notice describes how health information about you may be used and disclosed,
and how you can get access to that information. Please review this carefully,
and share with me any questions or concerns you may have.

My Legal Duties
District of Columbia and Federal laws require that I keep your health information private. Such laws require that I provide you with this notice informing you of my privacy policies, your rights, and my duties. I am required to abide by these policies until replaced or revised. I have the right to revise my privacy policies for all health records, including records kept before policy changes were made. Any changes in this notice will be made available to you before these changes take place.

The information disclosed to me in an evaluation, intake, or counseling or therapy session are covered by the law as protected health information. I respect the privacy of the information you provide me, and I abide by ethical and legal requirements of confidentiality and privacy of records.

Use of Information
Information about you may be used by me and other personnel associated with my office for purposes of diagnosis, treatment planning, treatment, quality enhancement, continuity of care, and administrative operations of my office.

Both oral information and written records about you cannot be shared with another party not affiliated with this office without the written consent of the client or the client's legal guardian or personal representative. It is my policy not to release any information about a client without a signed release of information except in certain emergency situations and other cases mandated by law. Some of these situations are noted below, and there may be other provisions provided by legal requirements.

Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Public Safety
Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, and when complying with worker's compensation laws.

Abuse
If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim, and their safety appears to be at risk, we may share this information with law enforcement officials to help prevent future occurrences and capture the perpetrator.

Prenatal Exposure to Controlled Substances
Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

In the Event of a Client's Death
In the event of an adult client's death, the spouse or legally-registered domestic partner of the client has a right to access the deceased spouse's/partner's records. In the event of a death of a minor client, the client's parents or legal guardian have a right to access the deceased child's records.

Professional Misconduct
Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional's actions, related records may be released in order to substantiate disciplinary concerns.

Judicial or Administrative Proceedings
Health care professionals are required to release records of clients when a court order has been placed.

Minors/Guardianship
Parents or legal guardians of non-emancipated minor clients have the right to access the client's records.

Other Provisions
When payment for services are the responsibility of the client, or a person who has agreed to providing payment, and payment has not been made in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the client's credit report may state the amount owed, the time-frame, and the name of the health care provider.

Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information which may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, and summaries.

Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed.

Phone, Mail and E-Mail Contact
In the event in which I or someone affiliated with my office shall telephone, mail or e-mail you for purposes such as appointment cancellations or reminders, or to give or obtain other information or feedback, we shall make efforts to protect your privacy and observe your wishes. Please notify me in writing where we may reach you by phone, mail or e-mail. Please also indicate in writing any restrictions you would like us to observe when contacting you or leaving messages for you by phone, mail or e-mail.

Your Rights
You have the right to request to review or receive your health care files. The procedures for obtaining a copy of your health information is as follows. You may request a copy of your records in writing with an original (not photocopied) signature. If your request is denied, you will receive a written explanation of the denial. Records for non-emancipated minors must be requested by their custodial parents or legal guardians. The charge for this service is $1 per page, plus postage.

You have the right to cancel a release of information by providing me a written notice. If you desire to have your information sent to a location different than our address on file, you must provide this information in writing.

You have the right to restrict which information may be disclosed to others when you sign a release of information. However, if I do not agree with these restrictions I am not bound to abide by them. In such a case, I shall inform you of my decision before I disclose any information. You then retain the right to cancel your release of information by providing me a written notice.

You have the right to request that information about you be communicated by other means or to another location. This request must be made to us in writing.

Your have the right to disagree with the medical records in my files. You may request that this information be changed. Although I might deny changing the record, you have the right to make a statement of disagreement, which will be placed in your file.

You have the right to know what information in your record has been provided to whom. You must request this in writing.

Questions, Concerns and Complaints
If you have any questions, concerns or complaints regarding these procedures or my actions effecting your privacy, please contact my office. I will respond to you in a timely manner. You may also submit a complaint to the U.S. Department of Health and Human Services and/or the District of Columbia Social Work Board. If you file a complaint I will not retaliate in any way.

Receipt of Notice

I have received a copy of this "Notice of Policy and Practices to Protect the Privacy of Your Health Information." I understand the privacy policies, limits of confidentiality, and my rights that are described in this document. I know I may ask Larry Cohen, LICSW, for further explanation of the provisions in this document at any time. Client's name (please print):

Signature: ___________________________________________

Date: _____/_____/_____

Signed by: __client __guardian __personal representative

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