Privacy Notice Form

Battlefield Counseling Centers

Please correct the errors described below.

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully!

This information is being provided as required by the federal Health Insurance Portability and Accountability Act.

I. Confidentiality

Battlefield Counseling Centers (BCC) has a duty to maintain privacy of your health information and to provide you with this notice. You will be asked to sign a Consent Form. Once you have signed the Consent Form, BCC may use or disclose your Protected Health Information (PHI) for purposes of diagnosis, treatment, obtaining payment, or to conduct healthcare operations. For example, if you choose to use insurance, to receive payment BCC must provide information about you to your insurance company.

As a rule, BCC will disclose no information about you, or the fact that you are our 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. If you request that BCC discloses information about you, BCC will require your written authorization to do so (unless the disclosure is related to the limits of confidentiality outlined below). You may revoke your authorization by contacting Battlefield Counseling Centers in writing at any time.

II. Limits to 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, and some required by law. BCC may use or disclose records or other information about you without your consent or authorization in the following circumstances:

  • Emergency: If you are involved in a life-threatening emergency and BCC cannot ask your permission, BCC will share information if BCC believes you would have wanted it to do so, or if BCC believes it will be helpful to you.
  • Child Abuse or Neglect Reporting: If BCC has reason to suspect that a child is abused or neglected, BCC is required by Virginia law to report the matter immediately and provide relevant information to the Virginia Department of Social Services.
  • Adult Abuse or Neglect Reporting: If BCC have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, BCC is required by Virginia law to immediately make a report and provide relevant information to the Virginia Department of Welfare or Social Services.
  • Health Oversight: Virginia law requires that licensed psychologists report misconduct by other psychologists. By law, if you describe unprofessional conduct by another mental health provider of any profession, BCC is required to explain to you how to make such a report. If you are yourself a health care provider, BCC is required by law to report to your licensing board that you are in treatment with BCC if it believes your condition places the public at risk. Virginia Licensing Boards have the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.
  • 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 under state law, and BCC will not release information unless you provide written authorization or a judge issues a court order. If BCC receives a subpoena for records or testimony, BCC will notify you so you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, BCC is required to place said records in a sealed envelope and provide them to the Clerk of Court. In civil court cases, therapy information is not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be “necessary for the proper administration of justice.” In criminal cases, Virginia has no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if BCC does 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: Under Virginia law, if BCC is engaged in my professional duties and you communicate a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and BCC believes you have the intent and ability to carry out that threat immediately or imminently, BCC is legally 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, BCC can be required to provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, or law enforcement officer, whether you are a minor or an adult.
  • Workers Compensation: If you file a worker’s compensation claim, BCC is required by law, 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 BCC will be made only with your written permission.

III. Patient’s Rights and Mental Health Clinician’s Duties

Patients Rights:

  • Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. If you ask BCC to disclose information to another party, you may request that BCC limits the information it discloses. However, BCC is not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell us: 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 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 BCC. Upon your request, BCC will send your bills to another address. You may also request that we contact you only at a certain phone number, or that we do not leave voice mail messages or use email correspondence). To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
  • Right to Inspect and Copy: You have the right to inspect and request copies of information that may be used to make decisions about your care. Usually this includes demographic and billing records but does not include psychotherapy notes. To inspect and/or receive copies of information, you must submit a request in writing. If you request a copy of information, BCC may charge a fee for the cost of copying, mailing or other supplies associated with your request. BCC must respond to your request within fifteen days of receipt. I may deny your access to PHI under certain circumstances, but in some cases, you may have the decision reviewed. BCC may also refuse to 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 health information about you is incorrect or incomplete, you may ask BCC to amend the information. You have the right to request an amendment for as long as the information is kept by BCC. Your request for amendment must be in writing and must provide a reason supporting your request. BCC may deny your request if you ask us to amend information that: 1) was not created by BCC; 2) is not part of the medical information kept by BCC; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
  • Right to an Accounting of Disclosures: You generally have the right to request an Accounting of Disclosures BCC have made of information about you. You must submit your request in writing to our published address. Your request must state a time period for the disclosures, which may not be longer than six years from the last published date of service.
  • Right to a Paper Copy: You have the right to obtain a paper copy of the notice from BCC upon request, even if you have agreed to receive the notice electronically. You may ask me to give you a copy of this notice at any time. BCC reserves the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information BCC already has about you as well as any information BCC receives in the future. The new notice will contain the effective date. A new copy will be given to you or posted in the waiting room. BCC will have copies of the current notice available on request.
  • Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket: You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket or in full for my services.
  • Right to Be Notified if There is a Breach of Your Unsecured PHI: You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) BCC's risk assessment fails to determine that there is a low probability that your PHI has been compromised.

Mental Health Clinician’s Duties:

  • Battlefield Counseling Centers is required by law to maintain the privacy of PHI and to provide you with a notice of its legal duties and privacy practices with respect to PHI.
  • BCC reserves the right to change the privacy policies and practices described in the notice. Unless we notify you of such changes, however, BCC is required to abide by the terms currently in effect. If we revise my policies and procedures, BCC will notify current clients and post the new policies in the waiting area.

Other uses and disclosures of Protected Health Information and any disclosure of Psychotherapy Notes will be made only with your written authorization. After such authorization is given, you may revoke that authorization at any time. This Notice may be amended as needed to comply with federal, state and professional requirements.

IV. Complaints

If you are concerned that BCC has violated your privacy rights, or you disagree with a decision made about access to your records, you may contact BCC directly at the office address, phone number or email address. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.

V. Effective Date and Changes to Privacy Policy

This notice will go into effect January 1, of the current calendar year. BCC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. BCC will notify current clients of changes in person or by mail and closed client cases can, if interested, call and ask if our policies have changed and obtain a copy by mail or view one on our website.

VI. Limits of Services and Assumption of Risks

Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, the improvements and any "cures" cannot be guaranteed for any condition due to the many variable that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of therapy sessions.

VII. Insurance Providers

Insurance companies and other third-party payers are given information they request regarding services to the clients. The type of information that may be requested includes: types of services, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, summaries, etc.

Practices to Protect the Privacy of Your Health Information

I have read and received the information contained in this document and understand how the Health Insurance and Portability and Accountability Act (HIPAA) impacts clinical and medical information about me and how I can get access to this information. I am also aware that should I have any questions concerning this policy I am free to discuss them at our next session or at any time in the future.

Due to security reasons you are unable to sign this form electronically. In lieu of an e-signature, please note that you acknowledge and understand the content of this form by typing your name in the field below.

Client Signature (Client's Parent/Guardian if under 18)

Cancellation Policy

If you are unable to attend an appointment, we request that you provide at least 48 hours advanced notice to our office. Since we are unable to use this time for another client, please note that you will be billed for the entire cost of your scheduled appointment if it is not timely cancelled, unless such cancellation is due to illness or emergency.

For cancellations made with less than 24 hour notice (unless due to illness or an emergency) or a scheduled appointment that is completely missed, you will be mailed a bill directly for the full session fee.

We appreciate your help in keeping the office schedule running timely and efficiently.

Due to security reasons you are unable to sign this form electronically. In lieu of an e-signature, please note that you acknowledge and understand the content of this form by typing your name in the field below.

Client Signature (Client's Parent/Guardian if under 18)

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