HIPPA Form

HIPAA Privacy Policy

    You are giving Dr. Smith permission to release your Personal Health Information (PHI) for the following three purposes:
  • Treatment: (for other psychologists in my office to provide crisis coverage or consultation regarding your case. More extensive case discussion within our practice or with outside health care providers requires your written permission).
  • Payment: Dr. Smith provides the basic minimum information on your monthly Statement so that your insurance may reimburse you.
  • Standard Office Practice: (such as scheduling appointments, record keeping, phone calls, required audits, administrative services, and treatment coordination).
  • Any other release of your PHI requires your written permission.

      Exceptions: Your psychologist may release confidential information without your consent if related to:
  • Ongoing child abuse, adult and domestic abuse
  • Serious threats to health or safety
  • Court orders or subpoenas
  • Workers compensation case
  • Licensing board investigations
    • Patients’ Rights: You have the right to:
  • Put restrictions on disclosures
  • Request that we send confidential information (such as billing) to alternate locations to protect your privacy
  • Receive a listing of disclosures made
  • Request and receive a full copy of the privacy policy (Listed in the Agreement to Therapy)
  • Submit a request to inspect or have a copy of your records (in coordination with your psychologist)
  • Psychologists’ Responsibilities: Dr. Smith is committed to maintaining the privacy of your PHI and will notify you of any changes in the privacy policies and practices. Please note that under HIPAA, your psychologist has the right to deny your request to inspect, copy, or amend your records, but will make every reasonable effort to discuss this with you.

    Privacy Complaints: If you feel that your rights have been violated, please direct your concerns ATTN: HIPAA Compliance Officer at Clinical Psychologists, P.C.

    Type your signature here
    01/01/1001