This notice describes
the confidentiality of your medical records, how the information is used, your rights, and how you may obtain this information.
This notice is effective 4-14-03. We reserve the right to change the notice as we feel necessary in the future. Notice changes
may be applied to all information held by Avery L Barber, MEd, LPC if it was created or received prior to the effective date
of the change.
Our Legal Duties
State and Federal
laws require that we keep your medical records private. Such laws require that we provide you with this notice informing you
of our privacy of information policies, your rights, and our duties. We are required to abide these policies until replaced
or revised. We have the right to revise our privacy policies for all medical records, including records kept before policy
changes were made. Any changes in this notice will be made available upon request before changes take place.
The contents of material disclosed to us in an evaluation, intake, or counseling session are covered by
the law as private information. We 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
about you may be used by the personnel associated with this clinic for diagnosis, treatment planning, treatment, and continuity
of care. We may disclose it to health care providers who provide you with treatment, such as doctors, nurses, mental health
professionals, and mental health students and mental health professionals or business associates affiliated with this clinic
such as billing, quality enhancement, training, audits, and accreditation.
verbal information and written records about a client cannot be shared with another party without the written consent of the
client or the client’s legal guardian or personal representative. It is the policy of this clinic not to release any
information about a client without a signed release of information except in certain emergencies or exceptions in which client
information can be disclosed to others without written consent. Some of these situations are noted below. There may be other
provisions, i.e., legal requirements.
Duty to Warn and Protect
When a client
discloses intentions or a plan to harm 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 a plan for suicide,
the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of
may be released for the public interest and safety for public health activities, judicial and administrative proceedings,
law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with
worker’s compensation laws.
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 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. If a client is the victim of abuse, neglect, violence, or a crime
victim, and their safety appears to be at risk, we may share this information with law enforcement officials to help prevent
future occurrences and capture the perpetrator.
Exposure to Controlled Substances
professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
the Event of a Client’s Death
In the event
of a client’s death, the spouse or parents of a deceased client have a right to access their child or spouse’s
misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional
or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be
released in order to substantiate disciplinary concerns.
Judicial or Administrative Proceedings
professionals are required to release records of clients when a court order has been placed.
legal guardians of non-emancipated minor clients have the right to access the client’s records.
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, progress 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 period, and the name of the clinic or
Insurance companies, managed care, and other third-party payers
are given information that they request regarding services to the client. Information that may be requested includes type
of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, and summaries.
Information about clients may be disclosed in consultations with other professionals
in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is
not disclosed. Clinical information about the client is discussed. Some progress notes and reports are typed within the clinic
by sources specializing in such procedures.
In the event the clinic or mental
health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive
other information, efforts are made to preserve confidentiality. Please notify us in writing where we may reach you by phone
and how you would like us to identify ourselves. For example, you might request that when we phone you at home or work, we
do not say the name of the clinic or the nature of the call, but rather the mental health professional’s first name
only. If this information is not provided to us (below), we will adhere to the following procedure when making phone calls:
First, we will ask to speak to the client (or guardian) without identifying the name of the clinic. If the person answering
the phone asks for more identifying information, we will say that it is a personal call. We will not identify the clinic (to
protect confidentiality). If we reach an answering machine or voice mail, we will follow the same guidelines.
related to the diagnosis or treatment of substance abuse may be protected by Title 42 (Code of Federal Rules of Privacy of
Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol
and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws.
You have the
right to request to review or receive your medical files. The procedure for obtaining a copy of your medical information is
as follows. You may request a copy of your records in writing with an original (not photocopied) signature. If your request
is denied, you will receive a written explanation of the denial. Their custodial parents or legal guardians must request records
for non-emancipated minors. The charge for this service is $ .75 per page for the first 25 pages and $.50 per page for pages
25-50, plus postage. You will also be charged for the time needed to review and prepare your record for release at a rate
of $70/hr of the clinician’s time.
You have the right to cancel a release
of information by providing us a written notice. If you desire to have your information sent to a location different from
our address on file, you must provide this information in writing.
You have the
right to restrict which information might be disclosed to others. However, if we do not agree with these restrictions, we
are not bound to abide by them.
You have the right to request that information
about you be communicated by other means or to another location. This request must be made to us in writing.
You have the right to disagree with the medical records in our files. You may request that this information
be changed. Although we might deny changing the record, you have the right to make a statement of disagreement, which will
be placed in your file.
You have the right to know what information in your record
has been provided to whom. Request this in writing.
If you desire a written copy
of this notice, you may obtain it by requesting it from the Clinic Owner at this location.