THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I am required by law to maintain the privacy and security of your protected health information ("PHI") and to provide you with this Notice of Privacy Practices ("Notice"). I must abide by the terms of this Notice, and I must notify you if a breach of your unsecured PHI occurs. I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office.

Except for the specific purposes set forth below, I will use and disclose your PHI only with your written authorization ("Authorization"). It is your right to revoke such Authorization at any time by giving me written notice of your revocation.

Uses (Inside Practice) and Disclosures (Outside Practice) Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Written Consent. I can use and disclose your PHI without your Authorization for the following reasons:

1.       For your treatment. I can use and disclose your PHI to treat you, which may include disclosing your PHI to another health care professional. For example, if you are being treated by a physician or a psychiatrist, I can disclose your PHI to him or her to help coordinate your care, although my preference is for you to give me an Authorization to do so.

2.       To obtain payment for your treatment. I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company to get paid for the health care services that I have provided to you, although my preference is for you to give me an Authorization to do so.

3.       For health care operations. I can use and disclose your PHI for purposes of conducting health care operations pertaining to my practice, including contacting you when necessary. For example, I may need to disclose your PHI to my attorney to obtain advice about complying with applicable laws. 

Certain Uses and Disclosures Require Your Authorization.

Psychotherapy Notes. I do not keep "psychotherapy notes" as that term is defined in 45 CFR § 164.501; rather, I keep a record of your treatment and you may request a copy of such record at any time, or you may request that I prepare a summary of your treatment. There may be reasonable, cost-based fees involved with copying the record or preparing the summary. Marketing Purposes.As a Licensed Mental Health Counselor ("counselor"), I will not use or disclose your PHI for marketing purposes. Sale of PHI. As a counselor, I will not sell your PHI in the regular course of my business.

Certain Uses and Disclosures Do Not Require Your Authorization. Subject to certain limitations mandated by law, I can use and disclose your PHI without your Authorization for the following reasons:

1.       When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law. 

2.       For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone's health or safety.

3.       For health oversight activities, including audits and investigations.  

4.       For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5.       For law enforcement purposes, including reporting crimes occurring on my premises. 

6.       To coroners or medical examiners, when such individuals are performing duties authorized by law.

7.       For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8.       Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9.       For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI to comply with workers' compensation laws.

10.   Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

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Certain Uses and Disclosures Require You to Have the Opportunity to Object.

1.       Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

YOUR RIGHTS REGARDING YOUR PHI
You have the following rights with respect to your PHI:

1.     The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say "no" if I believe it would affect your health care.

2.     The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3.     The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

4.     The Right to See and Get Copies of Your PHI. Other than "psychotherapy notes," you have the right to get an electronic or paper copy of your medical record and other information that I have about you.  
I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.

5.     The Right to Get a List of the Disclosures I Have Made.
You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.

6.     The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information.  I may say "no" to your request, but I will tell you why in writing within 60 days of receiving your request.

7.     The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If you think I may have violated your privacy rights, you may file a complaint with me, as the Privacy Officer for my practice, and my address and telephone number are: 4070 Aloma Avenue Suite 1030, Winter Park, FL 32792; phone 407-559-9013.

You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:

1.       Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;

2.       Calling 1-877-696-6775; or,

3.       Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

I will not retaliate against you if you file a complaint about my privacy practices.

The purpose of this form is to obtain your consent to participate in telemental health, which involves counseling by phone, video, or secure online email portal.

Benefits include:

1.       Convenience, since there is no travel time

2.       I can see you even if you are unable to get to my office, or when you are sick

3.       I can see you when you travel within the state, or even when you move within the state

Limitations/Risks include:

1.       There is a greater chance of misunderstanding -- we might not see each other's body language or hear subtle differences in voice tone that could easily be picked up in person

2.       If we meet in-person, I have more control of interruptions.  With video, I can't control your setting. 

3.       Internet connections could cease working or become too unstable to use

4.       You may feel more emotional distance due to the lack of in-person contact and presence.

5.       I cannot guarantee the privacy/confidentiality of conversations held via phone, as these can be intercepted accidentally or intentionally.  I cannot guarantee that hackers will not access video calls.

6.       I cannot immediately intervene if you are in crisis.

Is it right for you?  Telemental health is not a good fit for everyone.  If at any point you find the telehealth platform difficult or distracting to use, please let me know.  You have the right to discontinue receiving telehealth counseling at any time, without consequence.  I am always happy to discuss moving to phone or in-person sessions.  Likewise, if at any point I do not feel telehealth is working for me or for your treatment, I may discontinue this treatment option.

Logistics

1.       If we are connecting by video, I will send you a link to sign in to my secure and HIPAA-compatible video platform.  It is OK to "arrive" early -- I will connect with you at the time of the session.  If we are connecting by phone, I will call you at our scheduled time.

2.       I will be in a private location where I am alone.  You are responsible for your confidentially on your end, and need to be in a private location where you can speak openly without being overheard by others.

3.       At the start of the session, I may verify your location (street address). I can only provide therapy to you while you are in the state where I am licensed.  If I do not ask, please be sure to tell me if you are not at your home.

4.       Do not invite others to join us for any part of the session without discussing this with me in advance.

5.       Please be sure to have a cell phone with you or be near a phone in case video gets cut off.

You may have a better experience if you:

1.       Use a computer or tablet instead of a cell phone so that you can see me better. 

2.       Make sure your device is connected to power, or at least fully charged.

3.       Wear a two-ear wired headset with microphone (this can help us hear each other)

4.       Close other applications or programs on your computer.

5.       Make sure you have strong internet connection -- you may need to be near your modem.

6.       Consider how you will reduce interruptions (ex. talking to family in advance about your need for privacy during that hour, using a "do not disturb" sign on your door, etc.)

7.       Find a location where your face will be well-lit so I can see your facial expressions clearly.

Connection Loss:

1.       For video sessions:   If we lose our connection during our session, please quit and restart your search engine (or computer), and sign in again.  If you can't reconnect, I will call you.

2.       For phone sessions:  If we lose our connection during our session, I will call you again from an alternate number, which may show up as restricted or blocked -- please be sure to pick up the phone.   After 5 minutes if you have not heard from me, you may also attempt to call me at my office number, 407-559-9013.

Security

1. I utilize video software and hardware tools that adhere to security best practices and legal standards for the purposes of protecting your privacy. 

2. It is not recommended that you communicate using a public wireless network. 

3. You represent that you are not using someone else's device or your employer's computer, since employers have the right to monitor their equipment and networks, which could compromise your privacy. 

4. It is recommended that you have sufficient firewalls, anti-virus, and malware software.

5. You have the sole responsibility for security and privacy of your devices, equipment, and internet connection.

Recording of Sessions:

No sessions will be recorded by me, and the telehealth platform I use states that there is no recording of the session, no information collected, and no digital record saved afterwards.  Please note that recording or screenshots of any kind of any session are not permitted, and are grounds for termination of the client-therapist relationship.

Payment for Services: Payments for services will be made following the the session.  I will charge your credit card on file on the session date.  If you prefer not to use a credit card, you may pre-pay for sessions ahead of time by check or cash.  If you have insurance and I am on your insurance provider list, I will bill insurance on your behalf, but you remain responsible for any portion they do not pay.

Session Cancellations: Phone/video sessions are treated as in-office sessions when it comes to late cancellations and no-shows -- 24-hour advance notice is required, otherwise you will be charged the full session fee (not just a copayment), except for cases of unforeseen medical emergency.  Cancellations should be communicated via email and phone.

Emergencies and Confidentiality: Since you will be at a distance, I will utilize the emergency contact provided when registering as a client. 

If you do not expect to be at home for sessions, please plan to share your location with me during the session. 

If you are outside the area that I practice, I will identify emergency resources in your area.  If you are in crisis and we get disconnected, dial 988 for support, or call 911, go to your local emergency room or 2433 if you cannot reach me.

Please share with me if you have severe feelings of helplessness, hopelessness, or wanting to hurt yourself or others.  There are many steps I can take to help, even at a distance.  However, if I have extreme concerns about your safety at any time during a phone session, we may need to have you come to the office, or I may need to call your support system or emergency services to keep you safe.  

Please note that everything in our informed consent that you signed, including all the confidentiality exceptions, still applies during phone/video sessions.  By signing below, you agree that you have read and understand all of the above.  You give permission for me to communicate with your emergency contact if I am concerned about your safety.  You agree that you have had the chance to ask questions, that you understand the limitations associated with participating in telehealth sessions and consent to attend sessions under the terms described in this document.

PHONE/VIDEO SESSIONS:  When participating in video or phone sessions, I authorize my counselor to charge my credit/debit card after completion of the session. 

MISSED SESSIONS:  I understand that when I schedule an appointment, whether in- person or by video or phone, that time is held for me.  I also understand that insurance or EAP plans typically will not pay for missed sessions.  Therefore, I understand if I cancel or reschedule a session without 24-hour notice or if I do not show for the appointment, I authorize my counselor to charge my credit or debit card for the missed session.  If using insurance, the missed session fee will be the full session fee (not just my insurance copayment). 

HEALTH SAVINGS ACCOUNTS (HSA) CARDS:  If I have an HSA credit card, I authorize my counselor to charge the card for services after the completion of the session.  I understand that missed sessions cannot be billed to HSA credit cards.

OTHER CHARGES:  I understand other charges that may be billed to my credit/debit card are bank fees for bounced checks or any balances not paid within 30 days.

OTHER PAYMENT OPTIONS:  If I prefer not to use my credit card, I understand I may pay in advance for sessions by check or cash.  However, I understand that a credit card may be charged by my counselor to cover missed sessions, bounced checks, and unpaid balances.

CREDIT CARD INFORMATION:  In order to comply with Payment Card Industry Data Security Standards (PCI DSS), which are designed to prevent data theft and fraud, I understand that my credit/debit card information will not be stored in my medical record.  I understand that I will give my credit card information verbally to my counselor or I will enter it manually through the counselor's electronic health record software (CounSol) and it will be immediately entered into a credit card processing portal which performs data encryption for added security.

I verify that the credit card information I provide is accurate to the best of my knowledge. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest/additional costs incurred if denied.