Client HIPAA Acknowledgement

The Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology of Economic and Clinical Act (the HITECH Act) are regulatory standards for privacy and security. KC OMHC is committed to maintaining the privacy and integrity of privileged information and complying with all the requirements of HIPAA and the HITECH Act.

The American Recovery and Reinvestment Act of 2009 contains significant changes to the HIPAA Act of 1996. Security Breach notifications, applications to Business Associate Agreements, and improved enforcement are areas that have been incorporated into the American Recovery and Reinvestment Act of 2009.

An important part of HIPAA, known as the Privacy Rule, was developed to address the electronic transfer of private client information. The Privacy Rule seeks to prevent dissemination of protected health information (PHI), i.e., that sort of information that a client might have an expectation will not be shared without his or her permission. Enumerated in 45 C.F.R. § 164.514, an individual’s PHI includes information that could identify and/or reveal medical information about the person.

If you believe your privacy rights have been violated, you can file a complaint, or to receive more information about our privacy practices, please contact:

Corporate Office

5801 Allentown Road

Suite, 310

Suitland, MD 20746

Phone Number: 240.392.2876

One has the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event one feels privacy rights have been violated. We will not retaliate against one for filing a complaint.

For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services

Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

Toll Free: 877.696.6775

I have received a copy of the Privacy Practices/HIPAA forms. I understand the above information regarding protected health information (PHI).

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.