HIPAA provides you with expanded rights with regard to your Clinical Records and disclosures of Protected Health Information.  These rights include requesting that we amend your record, requesting restrictions on what information from your Clinical Record is supplied to others, requesting an accounting of most disclosures of Protected Health Information that you have neither consented to nor authorized, determining the location to which protected information disclosures are sent, having any complaints you make about our policies and procedures recorded in your records, and the right to a paper copy of Treatment Agreement, the attached Notice Form, and our privacy policies and procedures.  We are happy to discuss any of these rights with you.


  • We may occasionally find it helpful to consult with other professionals about your case. During a consultation, we make every effort to conceal your identity. Other professionals are also legally bound to keep this information confidential. We will note all consultations in your Clinical Record.
  • Disclosures required by health insurers, or to collect overdue fees are disclosed elsewhere in this Agreement.
  • If you present as a harm to yourself or others, we may be obligated to seek hospitalization for you, and/or to contact family members, and/or anyone else who can help provide protection.

There are some situations in which we are permitted or required to disclose information without either your consent or Authorization:

  • If you are involved in a court proceeding and a request is made for information concerning the professional services that we provided, or provide for you, such information is protected by the psychologist-patient privilege law.  We cannot provide any information without your written authorization, or court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.
  • If a government agency is requesting the information for health oversight activities, we may be required to provide this to them.
  • If you file a complaint or lawsuit against us, we may disclose any relevant information in order to defend myself.
  • If we are providing treatment for conditions directly related to a Worker’s Compensation claim, we may have to submit such records, upon appropriate request, to the Chairman of the Worker’s Compensation Board on such forms and at such times as the chairman may require.

There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about your treatment.  These situations are unusual in our practice.

  • If, in our professional capacity, we receive information from a child or the parents, guardian or other custodian of a child that gives us a reasonable cause to suspect that a child is being abused or neglected, the law requires that we report to the appropriate governmental agency, usually to the statewide central register of child abuse and maltreatment, or to the local child protective services office.  Once such a report is filed, we may be required to provide additional information.
  • If you communicate an immediate threat of serious physical harm to an identifiable victim, we may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for you.

If either such situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary.

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