Privacy and Consent
Listed below is information on our Privacy Practices and Consent for Services. All incoming clients of Suppression 2 Expression Counseling will receive a copy of these notices to review and sign. These are required to be completed before the start of the first session.
There is also a notice pertaining to Telehealth, this is not a form that will need to be signed, it is strictly informational.
Notice of Privacy Practices
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.
Suppression Expression Counseling, LLC (The Practice) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI I. OUR PLEDGE REGARDING HEALTH INFORMATION:
We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. We am required by law to:
• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• We 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 and on our website.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. We may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
1. Psychotherapy Notes. We do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
• For our use in treating you.
• For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
• For our use in defending myself in legal proceedings instituted by you.
• For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
• Required by law and the use or disclosure is limited to the requirements of such law.
• Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
• Required by a coroner who is performing duties authorized by law.
• Required to help avert a serious threat to the health and safety of others.
2. Marketing Purposes. Our Practice will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. Our Practice will not sell your PHI in the regular course of our business.
CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION:
Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:
• 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.
• 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.
• For health oversight activities, including audits and investigations.
• 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.
• For law enforcement purposes, including reporting crimes occurring on my premises.
• To coroners or medical examiners, when such individuals are performing duties authorized by law.
• 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.
• 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.
• For workers’ compensation purposes. Although our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.
• Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with one of our Providers. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer or can refer you to.
CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT:
Disclosures to family, friends, or others. We 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.
YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
• 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. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care.
• 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.
• The Right to Choose How We Send PHI to You. You have the right to ask your Provider to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
• 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 we have about you. We 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 we may charge a reasonable, cost based fee for doing so.
• The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which your Provider has disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost based fee for each additional request.
• 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 your Provider correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.
• 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.
EFFECTIVE DATE OF THIS NOTICE:
This notice went into effect on 04/08/2022
Consent for Services
Consent for Group Therapy
Please read through the information below and feel free to ask questions about group sessions and/or expectations to the coordinator of the group. Once you are ready to participate, please sign this informed consent form below so we will have on our records that you have read the information and that you have been properly informed about the therapy.
The Therapeutic Process
Group Therapy is a unique kind of therapy where a group of people who are likely experiencing similar challenges in the period of their lives gets together to share their difficulties which as a result give and at the same time, receive help from each other.
The sessions consist of processing on the issues that a member is involved where the others will give their feedback and reaction towards the said issue. This helps each member understand the issue from a different perspective in order to understand others. This also helps with one's reflection about their situation which can then help for insight and personal growth.
We make sure to maintain a safe environment that is conducive both for sharing and accepting each other where each can grow and trust one another and where each and everyone will feel respected and valued.
For the safety it is necessary that the following is required to be complied with by its members:
• Discussions made within the group session are not allowed to be discussed outside with anyone and should maintain the practice of confidentiality in order to build trust with fellow members.
• Members should maintain positivity and not induce disrespect among others.
• Members should not be drunk, nor they are allowed to take alcohol or take illicit drugs before or after therapy.
• Maintain conduct that brings respect to fellow members' thoughts, emotions, or behavior.
• Refrain from having a relationship with a fellow member other than therapeutic while engaged in the session.
We respect each and everyone's right to privacy and confidentiality and we shall make sure to maintain it that way. However, please understand that this is not absolute and is limited to provide for by law. Certain limitations are as follows:
• If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
• If a client threatens grave bodily harm or death to another person.
• If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
• Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
• Suspected neglect of the parties named in items #3 and # 4.
• Whenever we are summoned by court order to disclose information against a participant. However, we shall notify you and let you exercise your privilege in the right to deny the disclosure of your records with us.
• Your prior written consent to release records.
Occasionally your therapist may need to consult with other professionals in their areas of expertise in order to provide the best treatment. Information about you may be shared in this context without using your name.
The therapists should maintain a professional relationship with the participants at all times. Any relationship with a participant outside of the therapeutic setting may result in a "dual relationship" and may affect the goals of the session.