Spectrum expects that you will have a rewarding working relationship with your provider and that you will benefit from the treatment process. Spectrum wishes to inform you of the following:
You and your provider will be engaged in a cooperative working relationship. Each of you must contribute to make the relationship successful. There is no valid way to predict a specific treatment outcome. You have numerous rights which include:
The right to be aware of all aspects of the working relationship
The right to have all of your questions addressed regarding treatment
The right to participate actively in all aspects of treatment planning
The right to discontinue treatment at any time
All materials which is part of the treatment progress will be held in the strictest confidence by your provider except where state and/or federal law prevails. Information regarding your treatment may be shared among professionals within Spectrum Behavioral Management/Spectrum Psychiatry, PC. Consistent with applicable law, you should understand that confidentiality may be broken in cases where the provider believes that abuse or neglect has been rendered to a minor or vulnerable adult, where your provider believes that you represent an active threat to your well-being or to that of others and/or where the circumstances of state/federal law apply. Additional limits to confidentiality of Protected Health Information through the Health Insurance Portability and Accountability Act (HIPAA).
Appeals and Grievances:
I understand that I have the right to request reconsideration in the case that outpatient care is not authorized. I understand that the request for review can be made to my insurance company and that I risk nothing to exercise this right. I also understand that I have a right to file a complaint (Grievance) and risk nothing to exercise that right. Appeals and Grievances should be submitted in writing to the appropriate departments.
I hereby acknowledge that I have received, read and understand the above information regarding treatment, confidentiality and the Health Insurance Portability and Accountability Act (HIPAA) from Spectrum Behavioral Management/Spectrum Psychiatry, PC. I recognize that I may request a copy of Spectrum's complete privacy practices at any time.