Under the 1996 Health Insurance Portability and Accountability Act (HIPAA), you have specific Privacy Rights, as a client. The purpose of this form is to notify you of them:
- The right to inspect your own health information and obtain a copy (excluding psychotherapy notes).
- The right to request an amendment to health information (excluding psychotherapy notes).
- The right to receive an accounting of disclosures for purposes other than treatment, payment and healthcare operations.
- The right to request uses and disclosures of health information be restricted.
- The right to file a privacy complaint with your provider, the Office of Civil Rights (OCR) and/or the secretary of HHS (Department of Health and Human Services). You must do it in writing and you may either give it to me, at your next appointment, or send it by mail. To file a complaint with the Secretary of HHS, you may get assistance via the internet at https://compliancy-group.com/the-ocr-hipaa-violation-complaint-portal-and-portal-assistant/, you may email them at OCRMail@hhs.gov or call HHS, toll-free, at: 1-800-368-1019. If you choose to mail it, confirm the following address: HIPAA Complaint 7500 Security Blvd, C5-24-04 Baltimore, MD 21924.
- The information needed to file a complaint is your contact information (name, address, and phone), the name of the Covered Entity you are filing the complaint about, their tax identification #, Medicare identification #, if applicable, their address and phone number.
As your provider, I am legally required, under Federal Law and HIPAA, to protect your health data and to release only the minimum necessary information for the purposes of treatment, payment or healthcare operations, unless otherwise specifically authorized by you.
Confidentiality - No one will reveal information concerning your counseling to anyone outside of this office except as follows: (1) You consent it in writing; (2) if life or safety is seriously threatened (including abuse of children/elderly/disabled); (3) disclosure is required by law (such as a judge requesting records); (4) you file a benefit claim and the claim payer or your insurance requires information; (5) the files are audited by Quality Assurance bodies; (6) or the IRS; (7) I choose to disclose anonymous information pertaining to your case for the purpose of clinical and professional consultation, personal publication and/or educational illustration; (8) if, through the use of an encrypted email, fax or phone, your information, inadvertently, falls in the hands of someone other than the one intended; (9) other people who may have limited access to your file and/or may learn of your name associated with our counseling relation may include, but not be limited to: anyone working for me, the bank, collections, bankruptcy court, office staff/cleaning crew/landlords/representatives, personnel related to building emergencies, such as firemen.
Fees - Professional services are due when rendered. Please refer to my website for specific services amounts (https://www.ortigao.com/rates-insurance). Your signature below will indicate that you accept full responsibility for payment of any balance incurred for services; that you further understand that without two-(or three, if a 2-hr-appointment) full-business-days-notice of intention to cancel, that you will be charged for the full professional fee. E.g.: a Monday appointment needs to be canceled early Thursday or late Wednesday, the week prior. If you have health insurance plans, at no charge to you and, as a courtesy, I will bill them and collect from you your co-pay and/or deductible (in cash, check or card), if applicable. It is your responsibility to understand your insurance plan, keep up with your specific benefits and inform me of it and of any changes.
Video or phone consultations are billable the same or according to my hourly rate (e.g. 15 minutes = $50). Check with your insurance if your plan allows for telehealth. Any of my time dedicated to legal matters is billed at the $375/hr. rate. Non-payment of fees may result in termination of professional services and initiation of collection activity ($40 additional fee).
Parents/legal guardians: your signature below is your acknowledgment that if your child is 18 years old or older, but brought here by you, that you are ultimately responsible for the bills.
Furthermore, the Law requires both parents' signature in the treatment of minors; your signature below is not only your permission of my treatment of your child but also your acknowledgement that you have full legal authority to consent it, without obtaining approval of another person.
Regular email and text messages are not permitted, per Hipaa; only encrypted, which I initiate.
Your signature below is proof that you fully understand this form and accept it as the terms of your participation in this counseling. All of the above remains in effect until revoked by you in writing; should there be any changes to these forms, provided you are still actively involved in therapy, you will be notified and given new ones to sign, as well as a copy.
You assign the following person as your emergency contact and hold Rosario Ortigao harmless, should the need arise to notify the person below: