Notice of Privacy Policy | Arise Counseling

Health Insurance Portability Accountability Act (HIPAA)
Client Rights & Therapist Duties

This document contains important information about federal law, the Health Insurance Portability and
Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and
disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health
care operations.
HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of
PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to
your PHI in greater detail.
The law requires that I obtain your signature acknowledging that I have provided you with this. If you have
any questions, it is your right and obligation to ask so I can have a further discussion prior to signing this
document. When you sign this document, it will also represent an agreement between us. You may revoke
this Agreement in writing at any time. That revocation will be binding unless I have taken action in reliance
on it.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communication between a patient and a therapist. In most situations, I can
only release information about your treatment to others if you sign a written authorization form that meets
certain legal requirements imposed by HIPAA. There are some situations where I am permitted or required
to disclose information without either your consent or authorization. If such a situation arises, I will limit my
disclosure to what is necessary. Reasons I may have to release your information without authorization:
1. If you are involved in a court proceeding and a request is made for information concerning
your diagnosis and treatment, such information is protected by the psychologist-patient
privilege law. I cannot provide any information without your (or your legal representative's)
written authorization, or a court order, or if I receive a subpoena of which you have been
properly notified and you have failed to inform me that you oppose the subpoena. If you are
involved in or contemplating litigation, you should consult with an attorney to determine
whether a court would be likely to order me to disclose information.
2. If a government agency is requesting the information for health oversight activities, within
its appropriate legal authority, I may be required to provide it for them.
3. If a patient files a complaint or lawsuit against me, I may disclose relevant information
regarding that patient in order to defend myself.
4. If a patient files a worker's compensation claim, and I am providing necessary treatment
related to that claim, I must, upon appropriate request, submit treatment reports to the
appropriate parties, including the patient's employer, the insurance carrier or an authorized
qualified rehabilitation provider.
5. I may disclose the minimum necessary health information to my business associates that
perform functions on our behalf or provide us with services if the information is necessary
for such functions or services. My business associates sign agreements to protect the privacy
of your information and are not allowed to use or disclose any information other than as
specified in our contract.

There are some situations in which I am legally obligated to take actions, which I believe are necessary to
attempt to protect others from harm, and I may have to reveal some information about a patient's treatment:
1. If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or
neglected by a parent, legal custodian, caregiver, or any other person responsible for the
Arise Christian Counseling, LLC*Dina Richardson LCSW*(407)900.9756

7501 Citrus Avenue Box 7
Goldenrod, FL 32733
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child's welfare, the law requires that I file a report with the Florida Abuse Hotline. Once
such a report is filed, I may be required to provide additional information.
2. If I know or have reasonable cause to suspect that a vulnerable adult has been abused,
neglected, or exploited, the law requires that I file a report with the Florida Abuse Hotline.
Once such a report is filed, I may be required to provide additional information.
3. If I believe that there is a clear and immediate probability of physical harm to the patient, to
other individuals, or to society, I may be required to disclose information to take protective
action, including communicating the information to the potential victim, and/or appropriate
family member, and/or the police or to seek hospitalization of the patient.

CLIENT RIGHTS AND THERAPIST DUTIES
Use and Disclosure of Protected Health Information:
● For Treatment – I use and disclose your health information internally in the course of your
treatment. If I wish to provide information outside of our practice for your treatment by another
health care provider, I will have you sign an authorization for release of information.
Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
● For Payment – I may use and disclose your health information to obtain payment for services
provided to you as delineated in the Therapy Agreement.
● For Operations – I may use and disclose your health information as part of our internal
operations. For example, this could mean a review of records to assure quality. I may also use
your information to tell you about services, educational activities, and programs that I feel might
be of interest to you.

Patient's Rights:
● Right to Treatment – You have the right to ethical treatment without discrimination regarding
race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other
protected category.
● Right to Confidentiality – You have the right to have your health care information protected. If
you pay for a service or health care item out-of-pocket in full, you can ask us not to share that
information for the purpose of payment or our operations with your health insurer. I will agree
to such unless a law requires us to share that information.
● Right to Request Restrictions – You have the right to request restrictions on certain uses and
disclosures of protected health information about you. However, I am not required to agree to a
restriction you request.
● Right to Receive Confidential Communications by Alternative Means and at Alternative
Locations – You have the right to request and receive confidential communications of PHI by
alternative means and at alternative locations.
● Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI.
Records must be requested in writing and release of information must be completed.
Furthermore, there is a copying fee charge of $1.00 per page. Please make your request well in
advance and allow 2 weeks to receive the copies. If I refuse your request for access to your
records, you have a right of review, which I will discuss with you upon request.
● Right to Amend – If you believe the information in your records is incorrect and/or missing
important information, you can ask us to make certain changes, also known as amending, to your
health information. You have to make this request in writing. You must tell us the reasons you
want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why
within 60 days.
● Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy
in your email. If you completed this paperwork in the office at your first session a copy will be
provided to you per your request or at any time.

Arise Christian Counseling, LLC*Dina Richardson LCSW*(407)900.9756

● Right to an Accounting – You generally have the right to receive an accounting of disclosures of
PHI regarding you. On your request, I will discuss with you the details of the accounting
process.
● Right to Choose Someone to Act for You – If someone is your legal guardian, that person can
exercise your rights and make choices about your health information; I will make sure the person
has this authority and can act for you before I take any action.
● Right to Choose – You have the right to decide not to receive services with me. If you wish, I
will provide you with names of other qualified professionals.
● Right to Terminate – You have the right to terminate therapeutic services with me at any time
without any legal or financial obligations other than those already accrued. I ask that you
discuss your decision with me in session before terminating or at least contact me by phone
letting me know you are terminating services.
● Right to Release Information with Written Consent – With your written consent, any part of
your record can be released to any person or agency you designate. Together, we will discuss
whether or not I think releasing the information in question to that person or agency might be
harmful to you.
Therapist’s Duties:
● I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal
duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies
and practices described in this notice. Unless I notify you of such changes, however, I am required
to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you
with a revised notice in office during our session.
COMPLAINTS
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about
access to your records, you may contact me, the State of Florida Department of Health, or the Secretary of
the U.S. Department of Health and Human Services.
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE
TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED
THE HIPAA NOTICE FORM DESCRIBED ABOVE.
Client/Legal Guardian Signature: ____________________________________ Date: _________________
Printed Name: ___________________________________________________ Date: _________________
Client/Legal Guardian Signature: ____________________________________ Date: _________________
Printed Name: ___________________________________________________ Date: _________________
Clinician Signature: ______________________________________________ Date: _________________
Clinician Typed Name & Credentials: ________________________________ Date: _________________

Arise Christian Counseling, LLC*Dina Richardson LCSW*(407)900.9756

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