Consent to Treatment Online Form

Notice of Privacy PracticeStep 1 of 2

Extended Logo


This notice describes how medical and mental health 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 of your health information and to provide you with Notice about my privacy practices, legal duties and your rights concerning your health information. I am required to abide by the terms of this notice while it is in effect. I have the right at any time to change the terms of this notice. The new notice may apply to all health information I have no matter when I received it. In the event that this notice changes, I will mail you a copy of the revised notice to the address you have provided. The new Notice will also be made available upon request.

“Protected health information (PHI)” is information about you including demographic information and information related to your past and current physical or mental health condition and related health care services. When I collect this information from you, it is stored in a chart and on a computer. I may not use or disclose any information from your record unless you provide written authorization, except as described in this Notice.

How I may Use or Disclose Your Health Information
Providing treatment services, collecting payment and conducting health care operations are necessary activities for quality care. State and federal laws allow me to use and disclose your health information for these purposes.

Other uses and disclosures not described in this Notice require your signed authorization. For example, I must have your written authorization in order to share your PHI with your primary care physician or other mental health provider. You may revoke your authorization at any time with a written statement submitted to me. The revocation of your authorization will be effective immediately, except to the extent that: I have relied on it previously for the use and disclosure of your PHI; if the authorization was obtained as a condition of obtaining insurance coverage where other laws provide the insurer with the rights to contest a claim under the policy or the policy itself.


Child, Elderly or Disabled Adult Abuse- If I know or suspect that a child under the age of 18, an elderly person or disabled person has been abused or neglected, I am required by law to release PHI and make a report to the appropriate authorities and may be required to provide additional information.

Safety- I may disclose your PHI in order to reduce or prevent an imminent or serious threat to the health and safety of you or others. If a client threatens to harm himself/herself or others, I may be obligated to seek hospitalization for him/her, to contact family members or others who are reasonably able to prevent or lessen the threat and to contact the person whose safety has been threatened. If you report you have been sexually exploited by a mental health professional, I must report this.

Legal- I am required to release your PHI in compliance with a court order or subpoena. If a client files a complaint or lawsuit against me, I may disclose relevant PHI in order to defend myself. I may disclose your PHI to a law enforcement official for law enforcement purposes.

Worker's Compensation- I may disclose your PHI as necessary to comply with worker’s compensation laws.

Specialized government functions- If you are a member of the U.S. Armed Forces, I may disclose your PHI as required by military command authorities. I may also disclose PHI to authorized federal officials for national security reasons.

Vocational Rehabilitation Services and Similar Agencies- I may disclose PHI to agencies from which you are requesting assistance.

Health Oversight Activities- I may disclose PHI if requested by a government agency for health oversight activities.

Disaster Relief- I am permitted under the Privacy Rules to provide your PHI to disaster relief agencies.Marketing. I may contact you to provide appointment reminders (such as voice mail messages, postcards, or letters) or to give you information about other treatments or related services that may be of interest to you.


You have the right to:

Access- You have the right to request and inspect a copy of your health information in my records, with limited exceptions. Requests must be made to me in writing. I may deny your access to a portion of your health information. Access or denial will be provided within 30 days. If denied, you may request a review of the denial. Examples of reasons why I might deny the request include, but are not limited to the following: a determination that doing so might be harmful to you or another person. Because these are professional records, the contents can be misinterpreted and/or upsetting to an untrained reader. For this reason, if I decide to release your PHI for your review, I will make an appointment for your review the information in my presence so that you are provided with an opportunity to discuss the contents. Fees apply for this service. If you wish not to review the information with me, I recommend that you review the contents with another mental health professional. If you prefer, I will prepare a summary of your health information. You will have the right to a copy of parts or all of your health care information. Fees apply for this service. Current fees include $0.25 for each page copied, $15.00 per hour for staff time to locate and copy your PHI and postage, if you want the copies mailed to you. If you request an alternative format, I will charge a cost-based fee f or providing your health information in that format.

Amendment- You have the right to request that I amend your health information. This request must be made in writing and include the reasons for the request. I will consider the request, but I do not have to agree to the request. I may deny the request if the information was not created by me (unless you prove that the creator of the information is no longer available to amend the information), the information is not part of the records used to make decisions about you, if I believe the information is correct and complete, if I feel the information could be harmful to you to another person or if you would not have the right to see and copy the information as described above. If I accept your amendment, I will attach it as a permanent document in your health care record. If you make reference to specific documents in your health care record, I will append a note to each such document referring a future reader to your amendment. If you do not identify any specific documents or simply state “all” (or some similar language), then I will add your amendment as a separate document into the chart, but not append notes to any other documents.

Restrictions- You have the right to request restrictions on certain uses and disclosures of your PHI for treatment, payment and health care operations. I am not required to agree. If I do agree, I will abide by our agreement (except i n an emergency). Alternative communications- You have the right to request and receive confidential communications of your PHI by me. You may request to receive communication by alternative means or at alternative locations. For example, you may request that I use a specific telephone number or address to communicate with you. Requests must be made to me in writing and must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location.

Disclosure accounting- You have the right to receive an accounting of certain disclosures of your PHI made by me. Requests must be made in writing. You may ask for disclosures made up to 6 years before the time of your request. If you request this accounting more than once in a 12-month period, I may charge you a reasonable, cost based fee for responding to the additional requests.You also have the right to receive changes in these above stated policies. You have a right to receive a copy of this Notice.


If you have questions about this Notice, concerns about the privacy rights or disagree with a decision I make regarding privacy, you may discuss this with me. You may also send a written complaint to U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington, D.C. 20201. Complaints must be filed within 180 days of the time you knew or should have known of the violation. I support your right to the privacy of your PHI and will not retaliate against you for exercising your right to file a complaint.