DISCLOSURE STATEMENT AND HIPAA COMPLIANCE NOTICE OF PRIVACY PRACTICES IN A COUNSELING CENTER
As a new client to my counseling practice I would like to invite you to please read my Disclosure Statement, fill out the requested information, sign pages 5 and 6, make a copy for yourself, and return it to by email (frankr@seanet.com). Also please read and sign and email me the HIPAA EMAIL CONSENT FORM along with the Informed Consent for Telemental Healthcare Services form. Please read the attached Notice of Privacy pages.
This notice describes how medical information about you may be used and disclosed in a counseling center, and how you can get access to this information. This information will include the Protected Health Information (PHI), as that term is defined in privacy regulations issued by the United States Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and, as applicable, RCW Chapter 70.02 entitled “Medical records-- Heath Care Access and Disclosure.” Please review it carefully. I understand that your personal health information is very sensitive. I will not disclose your information to others unless you tell me to do so, or unless the law authorizes or requires me to do so.