Please answer the questions below, rating yourself on each of the criteria. As you answer each question, select the single choice that best describes how you have felt and conducted yourself over the past 6 months. This form can be be submitted and can be discussed during your next appointment with Dr. Sherman.

Dear Client,

Compassionate Recovery Care (hereinafter referred to as CRC) takes great care to protect your privacy. Below, you will find a government-mandated notice delineating your rights as a client. Your signature will indicate that you have received this notice. Any questions about this notice can be directed to the President of CRC, Roger Sherman, MD at (615) 674-0909.

 

Notice of Policies and Practices to Protect the Privacy of Your Health Information

 

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

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

 

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

• Treatment, Payment, and Health Care Operations

o Treatment is when a CRC doctor or provider provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be when your therapist consults with another health care provider, such as your family physician or another mental health provider;

o Payment is when CRC obtains reimbursement for your healthcare. Examples of payment are when CRC or biller discloses your PHI to your health insurer to obtain reimbursement for your health care to determine eligibility or coverage.

o Health Care Operations are activities that relate to the performance and operations of CRC’s 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 CRC’s office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• Disclosure applies to activities outside of CRC’s office, such as releasing, transferring, or providing access to information about you to other parties.

• Authorization is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.

II. Other Uses and Disclosures Requiring Authorization

CRC may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. In those instances when CRC or your therapist is asked for information for purposes outside of treatment, payment, or health care operations, your therapist or CRC will obtain an authorization from you before releasing this information.
You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) CRC has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

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

III. Uses and Disclosures without Authorization

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

• Child Abuse – If your therapist has reasonable cause to believe a child known to your therapist in a professional capacity may be an abused or neglected child, your therapist must report this belief to the appropriate authorities.

• Adult and Domestic Abuse – If your therapist has reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, your therapist must report this belief to the appropriate authorities.

• Health Oversight Activities – your therapist or CRC may disclose protected health information regarding you to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions.

• Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis, and treatment and the records thereof, such information is privileged under state law, and CRC must not release such information without a court order. The privilege does not apply when you are being evaluated for a third party where the evaluation is court-ordered. You must be informed in advance if this is the case.

• Serious Threat to Health or Safety – If you communicate to your therapist a specific threat of imminent harm against another individual or if your therapist believes that there is a clear, imminent risk of physical or mental injury being inflicted against another individual, your therapist may make disclosures that they believe is necessary to protect that individual from harm.

• Worker’s Compensation –your therapist may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law, that provide benefits for work-related injuries or illness without regard to fault.

 

IV. Client’s Rights and CRC Physician / Provider Duties

Client’s Rights:

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information.

• Right to restrict certain disclosures of PHI to health plans/insurance companies – If you wish to restrict disclosures to your health plan/insurance company, you must pay out of pocket in full for the health care service.

• 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 may not want a family member to know that you are seeing a therapist. At your request, CRC will send your bills to another address.)

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI including mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, CRC will discuss with you the details of the request for the access process.

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in record. CRC may deny your request. On your request, CRC 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. On your request, CRC 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 the notice from CRC upon request, even if you have agreed to receive the notice electronically.

• Right to be notified following a breach of unsecured protected health information – In the event there is a breach of unsecured protected health information, CRC will inform you of this.

 

CRC Physician / Provider Duties:

• CRC and staff are required by law to maintain the privacy of PHI and to provide you with a notice of CRC’s legal duties and privacy practices with respect to PHI.

• CRC reserves the right to change the privacy policies and practices described in this notice. Unless CRC posts and distributes a notice of such changes; however,

• CRC is required to abide by the terms currently in effect.

• If CRC revises policies and procedures, CRC will post the revisions and distribute the revisions to all clients who visit CRC’s office.

 

V. Questions and Complaints

If you have questions about this notice, disagree with a decision CRC makes about access to your records, or have other concerns about your privacy rights, you may contact Roger Sherman, MD at (615) 674-0909.

If you believe that your privacy rights have been violated and wish to file a complaint, you may send your written complaint to Roger Sherman, MD.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.

You have specific rights under the Privacy Rule. CRC will not retaliate against you for exercising your right to file a complaint.

 

VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice is effective on September 15, 2020.

CRC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that CRC maintains. CRC will provide you with a revised notice by posting the revisions and distributing the revisions to all clients who visit CRC’s office.

I have read and understood the above policies. I am consenting to participate in an assessment and or treatment with a doctor at CRC. I understand that no guarantees regarding the outcome of therapy can be given. CRC will use and share its knowledge and skills in good faith. Periodically during treatment, my doctor will evaluate progress and may change treatment goals as needed. If it becomes clear that there is a need to transition care to another therapist for any reason (e.g., the nature of symptoms being addressed, misfit of personality, lack of progress etc.,) I agree to discuss these concerns with my therapist and to participate in planning for transition to a new therapist if the issues cannot be resolved. In working toward my counseling goals with my therapist, I agree to abide by these policies. I have also received a copy of the “Notice of Policies and Practices to Protect the Privacy of Your Health Information” document in this packet.