NOTICE OF PRIVACY PRACTICES

Consent to Accept This Office’s Confidentiality Policies

 THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I.                    Confidentiality:

Uses and Disclosures of Information Requiring Your Authorization or Consent

As a rule, I will disclose no information about you, or the fact that you are my patient, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, I do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing the attached general consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me.

II.                  “Limits of Confidentiality:”

Possible Uses and Disclosures of Mental Health Records without Consent or Authorization

There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, [some because of policies in this office/agency], and some required by law. If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and consent to accept my policies about confidentiality and its limits. We will discuss these issues now, but you may reopen the conversation at any time during our work together.

·       Emergency

 I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required: · If you are involved in in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you. · · ·

·       Child Abuse Reporting:

 If I have reason to suspect that a child is abused or neglected, I am required to report the matter immediately to the Department of Child and Family Services.

·       Adult Abuse Reporting:

 If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required to immediately make a report and provide relevant information to the Department of Aged Concern or Social Services.

·       Court Proceedings:

 If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged, and I will not release information unless you provide written authorization, or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so that you (or your attorney, or I ) can file a motion to quash (block) the subpoena and can give reasons why I think your records should be protected from disclosure. in which your mental health is an issue (e.g., if you sue someone for mental/emotional damages), or in any case in which the judge deems the information to be “necessary for the proper administration of justice. Protections of privilege may not apply if I do an evaluation for a third party or where the evaluation is court- ordered. You will be informed in advance if this is the case. · · ·

·       Serious Threat to Health or Safety:

If I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally and ethically required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can be required to provide your records to the magistrate, your attorney or guardian ad litem, or law enforcement officer, whether you are a minor or an adult.

·       Workers Compensation:

 If you file a worker’s compensation claim, I may be required, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.

·       Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission.

III.                Patient’s Rights and Provider’s Duties: · · · ·

·       Right to Request Restrictions

You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.

·       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 me. Upon your request, I will send your bills to another address. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted. Right to an Accounting of Disclosures You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this Notice). On your written request, I will discuss with you the details of the accounting process.

·       Right to Inspect and Copy

In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to Page 2 of 3 provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding. · · ·

·       Right to Amend

If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted to me. In addition, you must provide a reason that supports s your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the clinical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.

·       Right to a copy of this notice

 You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Changes to this notice: I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for clinical information I already have about you as well as any information I receive in the future. The notice will contain the effective date. A new copy will be given to you in person or by email. I will have copies of the current notice available on request.

·       Complaints

 If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the Bermuda Health Council.

Patient’s Acknowledgement of Receipt of Notice of Privacy Practices

By purchasing and booking my online services, you acknowledgement access to this form. We can discuss these  policies, and you understand that I may ask questions about them at any time in the future. I consent to accept these policies as a condition of receiving mental health services.