This notice describes how health information about you may be used and disclosed,
and how you can get access to that information. Please review this carefully,
and share with me any questions or concerns you may have.
My Legal Duties
District of Columbia and Federal laws require that I and all associates of my office keep your health information private. Such laws require that I provide you with this notice informing you of my privacy practices, your rights, and my duties. I and all associates of my office are required to abide by these practices until replaced or revised. I have the right to revise my privacy practices for all health records, including records kept before changes were made. For as long as you are an active client of my office, I will provide you with any revisions of this Notice of Privacy Practices for your information and signature.
The information disclosed to me or to another associate of my office in an assessment, counseling or therapy session are covered by the law as protected health information. I and associates of my office respect the privacy of the information you provide us, and we abide by ethical and legal requirements of confidentiality and privacy of records.
Use of Information
Information about you may be used by me and other associates of my office for purposes of diagnosis, treatment planning, treatment, quality enhancement, continuity of care, and administrative operations of my office. Both oral information and written records about you cannot be shared with another party not affiliated with this office without the written consent of the client or the client's legal guardian. It is the policy of my office not to release any information about a client without a signed release of information except in certain emergency situations and other cases mandated by law. Some of these situations are noted below, and there may be other provisions provided by legal requirements.
Duty to Warn and Protect
When a client discloses intentions or a plan to kill another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies an imminent plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or that a child or vulnerable adult is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities.
Prenatal Exposure to Controlled Substances
Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
In the Event of a Client's Death
In the event of an adult client's death, the spouse or legally-registered domestic partner of the client has a right to access the deceased spouse's/partner's records. In the event of a death of a minor client, the client's parents or legal guardian have a right to access the deceased child's records.
Judicial or Administrative Proceedings
Health care professionals are required to release records of clients when a court order has been placed.
Parents or legal guardians of non-emancipated minor clients have the right to access the client's records.
When payment for services are the responsibility of the client, or a person who has agreed to providing payment, and payment has not been made in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, clinical notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the client's credit report may state the amount owed, the time frame, and the name of the health care provider.
Insurance & Managed Care
If authorized by the client in writing, insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information which may be requested includes type of services, dates and times of services, diagnosis, treatment plan, description of impairment, and progress of therapy.
Clinical information about clients may be disclosed and discussed in consultations with other health care professionals in order to provide the best possible treatment. In such cases the name of the client and any other identifying information are not disclosed.
Phone, Mail and E-Mail Contact
Whenever I or other associates of my office contact you by telephone, mail or e-mail, we will observe your wishes in order to protect your privacy. You will be asked to indicate in writing whether and where we may reach you by phone, mail or e-mail. You may also indicate in writing any restrictions you would like us to observe when contacting you by phone, mail or e-mail.
Social Contact & Social Networking
In order to maintain your privacy, and in to avoid dual relationships that could affect the services my office provides you, I and the other associates of my office do not socialize with clients or former clients, and we do not participate in electronic social networking with clients and former clients. If, by chance, any of us sees you in a public or social setting, we will try to acknowledge you, but will not engage in further conversation that could violate your privacy.
In the event of your incapacity or other emergency circumstances, I or other associates of my office may attempt to communicate with those persons whom you had previously designated in writing as emergency contacts in order to provide you with assistance in your best interest. If we determine it is necessary to communicate any of your protected health information with these or any other persons in the event of an emergency in order to provide you with assistance in your best interest, we will do so.
Notification of a Breach of Privacy
I and other associates of my office are required to notify you promptly if we discover a privacy breach of your health information.
You have the right to request to review or receive your health care files. You may request a copy of your records in writing with an original signature. Records for non-emancipated minors must be requested by their custodial parents or legal guardians. The charge for this service is $0.50 per page, plus any postage.
You have the right to disagree with the health care information in your files. You may request that this information be changed. Although I or other associates of my office might decline to change the record, you have the right to make a statement of disagreement which will be placed in your file.
You have the right to cancel a release of information by providing me or other associates of my office with a written notice.
You have the right to restrict which information may be disclosed to others when you complete and sign a release of information form. However, if I or other associates of my office do not agree with these restrictions, we shall inform you of this concern before we disclose any information. You then retain the right to cancel your release of information by providing us a written notice. In the case of information provided to a health plan for matters for which that health plan does not pay, I and other associates of my office are obligated to abide by any restrictions you make in writing when you complete and sign a release of information form.
You have the right to know what information in your record has been provided to whom. You must request this in writing.
Questions, Concerns and Complaints
If you have any questions, concerns or complaints regarding these practices, or regarding my actions effecting your privacy, or the actions of any associate of my office, please contact me. I will respond to you in a timely manner. You may also submit a complaint to the U.S. Department of Health and Human Services and/or the District of Columbia Social Work Board. If you file a complaint we will not retaliate in any way.
Receipt of Notice of Privacy Practices
I have received a copy of this Notice of Privacy Practices. I understand the privacy practices, limits of confidentiality, and my rights that are described in this document. I know I may ask Larry Cohen, LICSW, or other associates of his office, for further explanation of the provisions in this document at any time.
Client’s name (please print): __________________________________________________________________________________
Signature: ______________________________________________________________________ Date: ______/______/______
Signed by: __client __guardian __personal representative
If you have any questions or comments,
please email Larry Cohen, LICSW,
with offices in Washington, DC.