NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 

OUR PLEDGE REGARDING HEALTH INFORMATION:
We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We 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 we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of our legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.

 

We can change the terms of this Notice at any time, and such changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. We may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

 

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Psychotherapy Notes: We do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

• For our use in treating you.
• For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
• For our use in defending ourselves in legal proceedings instituted by you.
• For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA.
• Required by law and the use or disclosure is limited to the requirements of such law.
• Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
• Required by a coroner who is performing duties authorized by law.
• Required to help avert a serious threat to the health and safety of others.
  Marketing Purposes: As a psychotherapist, We will not use or disclose your PHI for marketing purposes.
• Sale of PHI. As a psychotherapist, We will not sell your PHI in the regular course of our business.

Billing A Third Party: With your consent, we may share your personal information for billing purposes to and from a 3rd party payer via email, internet, phone, mail carrier, fax etc.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, We can use and disclose your PHI without your Authorization for the following reasons:

• When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
• For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
• For health oversight activities, including audits and investigations.
• For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain an Authorization from you before doing so.
• For law enforcement purposes, including reporting crimes occurring on our premises.
• To coroners or medical examiners, when such individuals are performing duties authorized by law.
• For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
• Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
• For workers’ compensation purposes. Although our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.

Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.

 

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others: We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

• The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care.
• The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full: You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
• The Right to Choose How We Send PHI to You: You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
• The Right to See and Get Copies of Your PHI: Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost based fee for doing so.
• The Right to Get a List of the Disclosures We Have Made: You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, We will charge you a reasonable cost based fee for each additional request.
• The Right to Correct or Update Your PHI: If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information.We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.
• The Right to Get a Paper or Electronic Copy of this Notice: You have the right to receive a paper copy of this Notice, and you have the right to get a copy of this notice electronically such as by email. Even if you have agreed to receive this Notice via email, you also have the right to request a paper copy of it.

 

Acknowledgement of Receipt of Privacy Notice: Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. 

 

You Acknowledge that you have received a copy of Notice of Privacy Practices.

 

I AGREE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT, NOTICE OF PRIVACY PRACTICES.

Informed Consent for Psychotherapy

General Information:

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with us. 

 

The Therapeutic Process:

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. We cannot promise that your behavior or circumstance will change. We can promise to support you and do our very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

 

Confidentiality:

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

• If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.
• If a client threatens grave bodily harm or death to another person.
• If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
  Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
  Suspected neglect of the parties named in items #3 and # 4.
• If a court of law issues a legitimate subpoena for information stated on the subpoena.
• If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally we may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

COVID-19 Disclosure Agreement

This disclosure and agreement form seeks information and an agreement from you that we must consider before making decisions in the circumstance of the COVID-19 virus.

I knowingly & willingly consent to have mental health treatment facilitated during the COVID-19 Pandemic.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. It is impossible to determine who all has it and who does not; given the current limits in virus testing. 

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment radiation, chemotherapy and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. We strongly encourage you to please consider our safer telehealth option if you have any of these conditions.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus. If you have been exposed or could potentially be a carrier, please stay home and call us to reschedule your appointment if you have experienced any of the following:

Fever or chills
Shortness of breath or difficulty breathing
Cough
Fatigue
Headache
Muscle or body aches
New loss or reduction in taste or smell
A sore throat
Nausea or vomiting
Diarrhea
Have been in contact with someone who has tested positive for COVID-19
Have tested positive for COVID-19 (If you have tested positive for COVID-19 and have fully recovered we will consider if it is safe for you to return for an in-person visit with your therapist)
Have been tested for COVID-19 and are awaiting results
Have traveled outside the United States in the past 14 days
Have traveled within the United States by air, bus or train within the past 14 days

The CDC recommends masking when possible. We ask that you wear a mask to the office and within the waiting room area. Once you’re settled into your clinicians office for treatment, you may take off the mask. If you wish to keep on your mask during treatment you may. If you wish your clinician to wear their mask, please inform them.

I understand that I will contact the office of One By One Behavioral Health (and my Primary Care Physician) if I develop any COVID-19 symptoms.

I fully understand, acknowledge and accept full responsibility to the above information, risks and cautions regarding a compromised immune system in relation to COVID-19 and agree that One By One Behavioral Health will be held harmless for any actions or inaction, or for any direct or indirect result of any services provided by One By One Behavioral Health to myself or any guest/family member/friend that may attend with me at One By One Behavioral Health. 

I agree to the terms set forth in this COVID-19 Disclosure Agreement

PRACTICE POLICIES

 

APPOINTMENTS AND CANCELLATIONS: Please remember to cancel or reschedule 24 hours in advance. You will be responsible for a $25 Fee if cancellation is less than 24 hours and a $35 Fee for a NO SHOW. In addition, we do not bill insurance companies or 3rd party payers (ie Bishops) to cover this fee. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

 

The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.

 

A $10.00 service charge will be charged for any checks returned for any reason for special handling.

 

TELEPHONE ACCESSIBILITY: If you need to contact us between sessions, please leave a message on our voice mail. We are often not immediately available; however, we will attempt to return your call within 24 hours. Please note that Face-to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.

 

SOCIAL MEDIA AND TELECOMMUNICATION: Due to the importance of your confidentiality and the importance of minimizing dual relationships, We do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

 

ELECTRONIC COMMUNICATION: We cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, We will do so. While we may try to return messages in a timely manner, We cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telehealth, by the State of Utah. Under the Utah Telehealth Act of as of 5/9/2017, telehealth is broadly defined as “Asynchronous store and forward transfer” means the transmission of a patient’s health care information from an originating site to a provider at a distant site. “ If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1)You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telehealth consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telehealth. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the therapist.

 

MINORS: If you are a minor, your parents may be legally entitled to some information about your therapy. We will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

 

TERMINATION: Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. We may terminate treatment after appropriate discussion with you and a termination process if we determine that the psychotherapy is not being effectively used or if you are in default on payment. If therapy is terminated for any reason or you request another therapist, we can provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for eight consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.

Client further acknowledges that he/she may terminate or discontinue services at any time and that refunds are not issued for any reason.

 

I AGREE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT, PRACTICE POLICIES.

CONSENT FOR TELEHEALTH CONSULTATION

• I understand that my health care provider may consult with me through a telehealth consultation or session.
  I understand that the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
• I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the video conferencing connections are not adequate for the situation. 

 

CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE

 

Telehealth by SimplePractice is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. 

By signing this document, I acknowledge:

• Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
  Though my provider and I may be in direct, virtual contact through the
• Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
• The Telehealth by SimplePractice Service facilitates video conferencing and is not responsible for the delivery of any healthcare, medical advice or care.
• I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
• To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

 

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me.
• That I fully understand its contents including the risks and benefits of the procedure(s).
• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

I AGREE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.