if you don't have time to fill this out…
Prior to our first counseling session, I will need you to complete each of these 7 forms. After filling out the first form, you will be provided with the next form, until the last has been completed. This may take 15-30 minutes or more.

Form 3 of 7

Notice of Privacy Policies

03 – Notice of Privacy Policies
This notice describes how psychological and medical information may be used and disclosed:

  • Use and disclosure for Treatment, Payment and Health Care Options

I may use or disclose your protected health information (PHI) for treatment, payment, and health care operations 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 coordinate your treatment with other professionals.  For example, I may consult with your primary care physician, psychiatrist or another psychotherapist.  I also participate in supervision and peer consultation to discuss my work. I do not mention names or identifying information and the other professionals are bound by confidentiality.

“Payment” is when I obtain reimbursement for your treatment.  My practice will only disclose date of service, charge, type of service and diagnosis. Any other information will require written authorization from you

“Health Care Options”  I may be audited by regulatory agencies to ensure protection of your privacy.

  • Use and Disclosures requiring authorization

I will release information that you specify at your request.  You will be required to fill out an authorization form to specify the specific disclosures that you request. You may revoke your authorization at any time but this will not apply to anything I have already released at your request.

  • Use and Disclosures without Consent or Authorization

Serious Threat to Health or Safety: If I believe that you or someone else is in serious danger to include physical injury or death, I will take whatever steps are necessary to warn and protect.

Child Abuse: If I believe that a child is in endanger or being subjected to abuse or neglect, I will notify the appropriate agencies.

Adult: If I believe that a vulnerable adult is being subjected to abuse, neglect or exploitation, I will report the information to the appropriate agencies.

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for your records, the information will not be released without your authorization or a court order.

  1. Patient’s Rights and Therapist Duties:

Client’s Rights:

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about yourself.  Although, I’m not required to agree to the request, I will make every effort to honor the requested restrictions unless otherwise required by law.

Right to Receive Confidential Communication by alternative means or at alternative locations: You have the right to request that communication of confidential information be made by alternative means or sent to alternative locations. (For example: the bill may be sent to another location that is not your residence.)  You may also agree to have notification of a reminder of appointments by voice mail message, text message or email.

Right to Inspect and Copy: You have the right to obtain a copy of your clinical records although in some circumstances I provide a summary of information. To obtain a copy, please make your request in writing. In case of family or couple’s therapy, written consent is necessary by all parties before any part of the record can be released.

Right to Amend: You have a right to request an amendment of your protected health information for as long as your information is maintained in my records.  Again, there are denial and review processes, which I will discuss with you if you wish.

Right to an Accounting: You have the right to receive an accounting of any disclosure of PHI for which you have neither provided consent or authorization. (As described in section 3 above)

Therapist’s Duties

I am required by law to maintain the privacy of PHI and to provide you with this notice of my legal duties and privacy practices and your rights.

I reserve the right to change the privacy practices and policies described in this notice. Unless I notify you of the changes however, I’m bound to abide by the terms currently in effect.

If I change my policies and practices I will give or mail you a copy of the changes.

  1. Contact

I may contact you by telephone, text or email to remind you of appointments, information regarding clinical services or other health-related services that may be of interest to you. Your initials on the consent form and signature will allow me to leave you messages. Counseling sessions are conducted in person (face to face). If you and I agree, counseling services may also be conducted via telephone or through a secure and confidential telemedicine platform.

  1. Complaints

Any complaints should be filed with the Secretary of the U.S. Department of Health and Human Services or the Attorney General of New Jersey, Division of Consumer Affairs.

  1. Effective Date

This notice will go into effect on the date on which you sign the attached consent form.

Consent to the Release of Information

for the purposes of  Treatment* Payment**  and Health Care Operations***

* Treatment includes activities performed by Robert Watts, EdS, LPC, LCADC as well other health care professionals providing care to you such as your primary care doctor, other medical doctors or other health care professionals either involved in your treatment or involved as professional consultants (my clinical supervisor or licensed colleagues).  This consent includes disclosures to any professional who covers this practice.

**Payment includes uses and disclosures required for determining your eligibility for health insurance plan coverage and billing/receiving payment for your health benefit claims.

***Health Care Options includes administrative and business functions of this practice.

You should review my Notice of Privacy Practices for additional information about the uses and disclosures of information described in this consent prior to signing it.  I may need to change my privacy practices, if so, I will give you a copy of the new practices and their effective date.

As more fully explained in the Notice of Privacy Practices, you have the right to request restrictions on how I use and disclose your protected health information for treatment, payment and health care operations.  Please feel free to make these requests. Though I’m not required to agree to your request, I will make every effort to comply except under certain circumstances.

Please verify that you have received a copy of my Notice of Privacy Practices and Payment Policy *
Conducting Counseling Sessions *
Consent Right *

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