Polly Douse, Master’s Degree in Marriage and Family Therapy/Counseling
thercotn.com- 615-282-3730- firstname.lastname@example.org
This notice went into effect on May 10, 2022.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
REGARDING HEALTH INFORMATION
Health information about you and your health care is personal. I am committed to protecting your health information. I create a record of the care and services you receive from me. I 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 practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
- Keep your health information confidential unless otherwise permitted or required by law.
- 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.
- 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, and on my website.
HOW I MAY SHARE YOUR HEALTH INFORMATION
All information regarding your treatment will be held confidential unless you consent in writing to have all or portions of such information shared to specific persons or entities. When providing couple, family or group treatment, I will not disclose information outside the treatment context without a written consent from each individual competent to execute a waiver. However, I may disclose health information without your consent when permitted or required by state or federal law, including:
- In response to a subpoena, court order, or other request authorized by state or federal law;
- Reporting suspected child, elder, or dependent adult abuse; and
- Preventing or reducing a serious threat to your health or safety or the health or safety of another person.
CONFIDENTIALITY WITHIN TREATMENT
I may consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name or other information that could reasonably lead to your identification.
In the context of couple, family or group treatment, I will not reveal any individual’s confidences to the others in the client unit without the prior written permission of that individual.
Further, if we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
ACCESS TO RECORDS
You have the right to request a copy or summary of your treatment records. To request a copy of your records, please submit a written request to us at [email@example.com]. When providing couple, family, or group treatment, I will not provide access to records without a written consent from each individual competent to execute a waiver. I may limit your access to your records only where I determine that such access could cause you serious harm.
ACKNOWLEDGEMENT OF PRIVACY STATEMENT
BY USING THIS WEBSITE, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS PRIVACY STATEMENT.