Center For Individual & Family Therapy A Christian Counseling Center Family Forms (Page 4 of 6) in pdf

copy of the subpoena, affidavit and the appropriate notice, and you have not notified me that you are

bringing a motion in the court to quash (block) or modify the subpoena. The privilege does not apply

when you are being evaluated for a third party or where the evaluation is court-ordered. I will inform

you in advance if this is the case.

•

Serious Threat to Health or Safety: If you communicate to me a serious threat of physical violence

against an identifiable victim, I must make reasonable efforts to communicate that information to the

potential victim and the police. If I have reasonable cause to believe that you are in such a condition, as

to be dangerous to yourself or others, I may release relevant information as necessary to prevent the

threatened danger.

•

Worker’s Compensation: If you file a worker's compensation claim, I must furnish a report to your

employer, incorporating my findings about your injury and treatment, within five working days from the

date of the your initial examination, and at subsequent intervals as may be required by the

administrator of the Worker’s Compensation Commission in order to determine your eligibility for

worker’s compensation.

IV. Patient's Rights and Therapist’s Duties

Client’s Rights:

•

Right to Request Restrictions –You have the right to request restrictions on certain uses and

disclosures of protected health information about you. However, I am not required to agree to a

restriction you request.

•

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.)

•

Right to Inspect and Copy – You have the right to inspect or obtain a copy of PHI in my mental

health and billing records used to make decisions about you for as long as the PHI is maintained in

the record. I may deny your access to PHI under certain circumstances, but in some cases you may

have this decision reviewed. On your request, I will discuss with you the details of the request/denial

process.

•

Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is

maintained in the record. I may deny your request. On your request, I will discuss with you the

details of the amendment process.

•

Right to an Accounting – 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 request, I will discuss with you the details of the accounting process.

•

Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon

request, even if you have agreed to receive the notice electronically.

Therapist’s Duties:

•

I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal

duties and privacy practices with respect to PHI.

•

I reserve the right to change the privacy policies and practices described in this notice. Unless I

notify you of such changes, however, I am required to abide by the terms currently in effect.

V. Complaints

•

If you are concerned that a therapist has violated your privacy rights, or you disagree with a decision

he or she has made about access to your records, you may contact the Clinical Director at 714-558-

9266.

•

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human

Services. The person listed above can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on May 1, 2005. CIFT reserves the right to change the terms of this notice and to

make the new notice provisions effective for all PHI that our therapists maintain. We will provide you with a

revised notice by U.S. Mail.

Please feel free to discuss any concerns you may have with your therapist as they arise or

contact our Clinical Director at 714-558-9266 x953.

Signature

Client Name (Please Print)

Date

Client Representative Signature

Date

(If Rep., Print Name & Relationship to Client)

Center For Individual & Family Therapy A Christian Counseling Center Family Forms Page 4

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