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Office Policies for Psychology Practice.
(HIPAA Notice of Privacy Practices and revised Office Policy added May 2003.)
New Patients: You may print out my Office Policies, the HIPAA Notice of Privacy Practices, and the Consent to Use or Disclose Information forms from this page. You may want to print out two copies so you can keep one for your files. Prior to your first appointment, read these policies and initial each page of the Office Policies. Sign and date the last page of each form. Bring these to your first appointment so you can give them to Dr. Ellis for his files. If you have any questions, you may contact Dr. Ellis or discuss these questions with him at your first appointment.
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Office Policies & General Information Agreement for Psychotherapy Services
Dale Ellis, Ph.D.
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client's) written permission, except where disclosure is required by law. Most of teh provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.
When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse ore neglect; where a client presents a danger to self, to others, to property, or is gravely disabled.
When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Dr. Ellis. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Dale Ellis will use his clinical judgment when revealing such information. Dr. Ellis will not release records to any outside party unless he is authorized to do so by all adult family members who were part of the treatment.
Emergencies: If there is an emergency during our work together, or in the future after the end of therapy where Dale Ellis becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, he will do whatever he can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, he may also contact the person whose name you have provided on the biographical form.
Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you instruct Dale Ellis, Ph.D. only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly the Psychotherapy Notes will not be disclosed to your insurance carier. Dr. Ellis has no control or knowledge over what insurance companies do with the information he submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement or a treatment report required by the insurance company carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance. One form of this risk stems from the fact that mental health information is entered into big insurance companies' computers and soon will also be reported to a, congress approved, National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank data base is always in question as computers are inherently vulnerable to break ins and unauthorized access. Medical data has been reported to be sold, stolen or accessed by enforcement agencies.
Confidentiality of E-mail, Cell Phone and Faxes Communication: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentialityof such communication can be compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can easily be sent erroneously to the wrong address. Please notify Dr. Ellis at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices. Please do not use e-mail or faces for emergencies.
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc. ...), neither you (client's) nor you attorney's, nor anyone else acting on your behalf will call on Dale Ellis, Ph.D. to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
Consultation: Dr. Ellis consults with other professionals regarding his clients; however, a client's name or other identifying information is never mentioned. The client's identity remains completely anonymous, and confidentiality is fully maintained.
*Considering all of the above exclusions, if it is still appropriate, upon your request, Dr. Ellis will release information to any agency/person you specify unless Dr. Ellis assesses that releasing such information might be harmful in any way.
Initial p. 1 of 4.
TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Dr. Ellis between sessions, please leave a message on the answering machine or voice mail, Dr. Ellis (925) 943 1137 and your call will be returned as soon as possible. Dr. Ellis checks his messages a few times a day, unless he is out of town. If an emergency situation arises, please indicate it clearly in your message. If you need to talk to someone right away, you can call the Crisis Hotline 1 800 833 2900, the Police (911), or other Crisis Hotlines listed in the Customer Guide section of your Pacific Bell Phone Book. Your Insurance Company may also have a 24 hour crisis line available.
PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee of per 45 minute session (or your co-pay) at the beginning or end of each session unless other arrangements have been made. The initial evaluation session is $ 160 and sessions after that are . If you are unable to afford the standard fee, you may discuss other fee arrangements with Dr. Ellis. Telephone conversations over 10 minutes, site visits, report writing and reading, consultation with other professionals, releasing information, reading records, longer sessions, travel time, etc... will be charged at the same standard rate ( per 45 minutes), unless indicated and agreed otherwise. Please notify Dr. Ellis if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance company. You may arrange with Dr. Ellis for him to provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. As indicated in the section Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies. If is your responsibility to verify the specifics of your coverage.
MEDIATION & ARBITRATION: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Dr. Ellis and client(s). The cost of such mediation, if any, shall be split equally, unless
otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Contra Costa County, California in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Dr. Ellis can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceeding shall be entitled to recover a reasonable sum as and for attorneys' fees. In the case of arbitration, the arbitrator will determine that sum.
THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you (or your child, if your child is being seen). These include improving interpersonal relationships, reduction or elimination of symptoms, and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. Dr. Ellis will ask for your feedback and views on your therapy, its progress and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be
Initial p. 2 of 4.
helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing discomfort or strong feelings of anger, sadness, worry, fear, etc... or experiencing anxiety, depression, insomnia, etc... Dr. Ellis may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations which may cause you to feel upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place may result in changes that were not originally intended. Disruptions in your life and emotional distress may occur. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Dr. Ellis is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his assessment of what will best benefit you. These approaches include psychodynamic, cognitive behavioral, developmental, family/systems, play therapy (for children), transpersonal (spiritual), indigenous/shamanic, EMDR, EFT, Gendlin's focusing technique, Control Mastery theory, or psycho educational.
These methods include a kinesiology technique called "energy checking" or "muscle testing" which is used to obtain information and determine how energy patterns affecting my body and mind may relate to the goals or problems I wish to address in my work with Dr. Ellis. In this technique Dr. Ellis applies physical pressure in order to determine whether a muscle stays firm or loses strength as I resist the presssure and focus my mind on a particular thought, emotion, issue, problem or goal. This information is used to assist us in how to best proceed including which energy/meridian points may be best to use. Energy treatment points, adapted from the practice of acupressure, may be stimulated for the purpose of correcting disturbed energy patterns that may underlie emotional and psychological problems and/or may prevent or interfere with the achievement of goals and objectives. Stimulation may include touching, rubbing, or tapping a point. In most cases I will be instructed on how to simulate the points myself. In some instances, Dr. Ellis may ask my consent to directly work with specific treatment points. I understand that the use of energy checking and energy treatment points within the field of psychotherapy (and personal coaching) is a new development and that at this time there is little published research in established scientific journals investigating these methods. While clinical reports of successful outcomes using these methods in the field of Energy Psychology do exist in the published literature and while the methods are being developed and refined under the auspices of organizations such as the Association of Comprehensive Energy Psychology, I understand that clinical reports do not constitute scientific evidence. I also understand that even if the clinical effectiveness of these methods is scientifically established, results will vary from client to client.
Discussion of Treatment Plan: Within a reasonable period of time after beginning treatment, Dr. Ellis will discuss with you (client) his working understanding of the problem, treatment plan, therapeutic objectives and his view of the possible outcomes of treatment. If it is possible to estimate length of treatment, Dr. Ellis will try to answer your questions in this area, but frequently it is only possible to give general, not specific, estimates of length of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, Dr. Ellis's expertise in employing them, or about the treatment plan, please ask and he will answer them. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that Dr. Ellis does not provide, he will assist you in obtaining those treatments.
Ending Therapy: After the first couple of meetings, Dr. Ellis will assess if he can be of benefit to you. Dr. Ellis does not accept clients who, in his opinion, he cannot help. In such a case, he will give you referrals that you can contact. If at any point during psychotherapy Dr. Ellis assesses that he is not effective in helping you reach the therapeutic goals he will discuss it with you and, if appropriate, terminate treatment. In such a case, he would give you referrals that may be of help to you. If you request it and authorize it in writing, Dr. Ellis will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional's opinion or wish to consult with another therapist, Dr. Ellis will assist you in finding someone qualified, and if he has your written consent, he will provide her or him with the essential information needed. You may choose to end therapy at any time, but it is usually best to discuss this with Dr. Ellis so he can assess whether it might be in your best interest to continue therapy. Whatever may be Dr. Ellis's view on this, you have the right to make your own decision. If you choose to end therapy, Dr. Ellis will offer to provide you with names of other professionals whose services you might prefer.
Dual Relationships: Not all dual relationships are unethical or avoidable. Therapy never involves sexual or business relationships or any other dual relationship that impairs Dr. Ellis's objectivity, clinical judgment, therapeutic effectiveness or can be exploitive in nature. Dr Ellis will assess carefully before entering into non-sexaual andnon-exploitative dual relationships with clients. Walnut Creek is a small city and some clients know each other and may know Dr. Ellis from the community. Consequently you may encounter someone you know when coming to or leaving an appointment or you may se Dr. Ellis out in the community. Dr. Ellis will never acknowledge working therapeutically with anyone without his/her written permission. Many clients choose Dr. Ellis as their therapist because they know him before they enter into therapy with him and/or are aware of his stance on the topic. Nevertheless, Dr. Ellis will discuss with you, his/her client/s, the often-existing cmplexities, potential benefits , and difficulties that may be involved in such relationships. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time. It is your, the client's, responsibility to communicate to Dr. Ellis if the dual relationship becomes uncomfortable for you in any way. Dr. Ellis will always listen carefully and respond accordingly to your feedback. He will discontinue the dual relationship if he finds it interfering with the effectiveness of the therapeutic process or the welfare of the client and, of course, you can do the same at any time.
CANCELLATION: Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 72 hours (3 days) notice is required for rescheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions so you will be responsible for this fee. .
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It is Dr. Ellis's informal policy that if he and the client are able to reschedule an appointment within the same week as the missed appointment (less than 72 hour notice), the client will not be charged for the missed appointment. It is not Dr. Ellis's responsibility to somehow come up with an alternate time that works for the client. If for any reason, it is not possible to schedule another time or it does not work out, it is the client's responsibility to pay for the missed session.
I have read the above Agreement and Office Policies and General Information carefully. I understand them and agree to comply with them.
CLIENT NAME:(PRINT):____________________________
Signature:_______________________ Date:_________
CLIENT'S (or parent's) NAME:
(PRINT):________________________
Signature: ______________________ Date:__________
THERAPIST (print): __________________
Signature: ______________________ Date:__________
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Intake Form
(You may print out this form, complete it, and bring it to your first session. If more information is needed, I can mail a 3 page biographical history form to you prior to your first appointment.)
INTAKE FORM
Dale Ellis, Ph.D. Licensed Psychologist (PSY8720)
NAME: ________________________ MALE/FEMALE: ___ DATE: ______
ADDRESS: __________________________________________________________________
TELEPHONE: H : __________ W/OFF.: ___________ D.O.B.: ______ Age: __ SS# __________________ Email: _________________
HIGHEST GRADE/DEGREE: __________ REFERRED BY: ___________________
PERSON AND NO. TO CALL IN EMERGENCY: _____________________________
MARITAL STATUS: ___ Former/Present marriage(s) (years): ________
SPOUSE NAME: ______________ AGE: ___ OCCUPATION: __________________
CHILDREN/STEP/GRAND (names/ages) : ________________________________
SIBLINGS (names/ages): ______________________________________________
PARENTS/STEP-PARENT(s) (Ages or year of death): _______________________
OCCUPATION/POSITION: _____________________________________________
INSURANCE INFO.: ___________________________________________________
PRESENTING PROBLEM: _____________________________________________
_____________________________________________________________
MEDICAL DOCTORS: ______________ PHONE: ________ LAST EXAM: _____
PAST/PRESENT MEDICAL CARE (Specify: major problems, accidents, hospitalizations, current medication):
_____________________________________________________________
_____________________________________________________________
PAST/PRESENT COUNSELING/PSYCHOTHERAPY/MENTAL HOSPITALS:
1. Therapist: ___________ Dates: __ to __ Phone: ______ Address: ________
Initial reason: __________ Process and outcome: ____________________
2. Therapist: __________ Dates: __ to __ Phone: ______ Address: _________
Initial reason: _________ Process and outcome: _____________________
PAST/PRESENT DRUG/ALCOHOL USE/ABUSE (any addiction, AA/NA/etc.): _____
_____________________________________________________________
FAMILY HISTORY OF ALCOHOLISM, METAL ILLNESS, VIOLENCE, SUICIDE: __
__________________________________________________________________
Use the space on the back of this form if you need to give further information
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HIPAA NOTICE OF PRIVACY PRACTICES
I. 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.
II. IT IS MY LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
By law I am required to insure that your PHI is kept private. The PHI constitutes information created or noted by me that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. I am required to provide you with this Notice about my privacy procedures. This Notice must explain when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, or analyze information within my practice; PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside my practice. With some exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, I am always legally requred to follow the privacy practices described in this Notice. Please note that I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI already on file with me. Before I make any important changes to my policies, I will immediately change this Notice and post a new copy of it in my office and on my website. You may also request a copy of this Notice from me, or you can view a copy of it in my office or on my website, which is located at www.dr.ellis.20m.com
III. HOW I WILL USE AND DISCLOSE YOUR PHI
I will use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of my uses and disclosures, with some examples.
A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I may use and disclose your PHI without your consent for the following reasons:
1. For treatment. I may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treating you, I may disclose your PHI to her/him in order to coordinate your care.
2. For health care operations. I may disclose your PHI to facilitate the efficient and correct operation of my practice. Examples: Quality control - I might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. I may also provide your PHI to my attorneys, accountants, consultants, and others to make sure that I am in compliance with applicable laws.
3. To obtain payment for treatment, I may use and disclose your PHI to bill and collect payment for the treatment and services I provided you. Example: I might send your PHI to your insurance company or health plan in order to get payment for the health care services that I have provided to you. I could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for my office.
4. Other disclosures. Examples: Your consent isn't required if you need emergency treatment provided that I attempt to get our consent after treatment is rendered. In the event that I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) but I think that you would consent to such treatment if you could, I may disclose your PHI.
B. Certain Other Uses and Disclosures Do Not Require Your Consent. I may use and/or disclose your PHI without your consent or authorization for the following reasons:
1. When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: I may make a disclosure to the appropriate officials when a law requires me to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.
2. If disclosure is compelled by a party to a proceeding before a court of an administrative agency pursuant to its lawful authority.
3. If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.
4. If disclosure is compelled by the patient or the patient's representative pursuant to California Health and Safety Codes or to corresponding federal statutes of regulations, such as the Privacy Rule that requires this Notice.
5. To avoid harm. I may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public.
6. If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger.
7. If disclosure is mandated by the California Child Abuse and Neglect Reporting law. For example, if I have a reasonable suspicion of child abuse or neglect.
8. If disclosure is mandated by the California Elder/Dependent Adult Abuse Reporting law. For example, if I have a reasonable suspicion of elder abuse or dependent adult abuse.
9. If disclosure is compelled or permitted by the fact that you tell me of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.
10. For public health activities. Example: In the event of your death, if a disclosure is permittted or compelled, I may need to give the county coroner information about you.
11. For health oversight activities. Example: I may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization or provider.
12. For specific government functions. Examples: I may disclose PHI of military personnel and veterans under certain circumstances. Also, I may disclose PHI in the interests of national security, such as protecting the President of the United States or assisting with intelligence operatons.
13. For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research.
14. For Worker's Compensation purposes. I may provide PHI in order to comply with Workers' Compensation laws.
15. Appointment reminders and health related benefits or services. Examples: I may use PHI to provide appointment reminders. I may use PHI to give you information about alternative treatment options, or other health care services or benefits I offer.
16. If an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.
17. I am permitted to contact you, without your prior authorization, to provide appointment reminders or information bout alternative or other health-related benefits and services that may be of interest to you.
18. If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law. Example: When compelled by the U.S.Secretary of Health and Human Services to investigate or access my compliance with HIPAA regulations.
19. If disclosure is otherwise specifically required by law.
C. Certain Uses and Disclosures Require You to Have the Opportunity to Object. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations.
D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections IIIA IIIB, and IIIC above, I will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (assuming that I haven't taken any action subsequent to the original authorization) of your PHI by me.
IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
These are your rights with respect to your PHI:
A. The Right to See and Get Copies of Your PHI. In general, you have the right to see your PHI that is in my possession, or to get copies of it; however, you must request it in writing. If I do not have your PHI, but I know who does, I will advise you how you can get it. You will receive a response from me within 30 days of my receiving your written request. Under certain circumstances, I may feel I must deny your request, but if I do, I will give you, in writing, the reasons for denial. I will also explain your right to have my denial reviewed. If you ask for copies of your PHI, I will charge you not more than $.25 per page. I may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.
B. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that I limit how I use and disclose your PHI. While I will consider your request, I am not legally bound to agree. If I do agree to your request, I will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that I am legally required or permitted to make.
C. The Right to Choose How I Send Your PHI to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). I am obliged to agree to your request providing that I can give you the PHI, in the format you requested, without undue inconvenience.
D. The Right to Get a List of the Disclosures I Have Made. You are entitled to a list of disclosures of your PHI that I have made. The list will not include uses or disclosures to which you have already consented, I.E., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. After April 15, 2003, disclosure records will be held for six years. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I give you will include disclosures made in the previous six years (the first six year period being 2003-2009) unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no cost, unless you make more than one request in the same year, in which case I will charge you a reasonable sum based on a set fee for each additional request.
E. The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that I correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of my receipt of your request. I may deny your request, in writing, if I find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d) written by someone other than me. My denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and my denial be attached to any future disclosures of your PHI. If I approve your request, I will make the change(s)to your PHI. Additionally, I will tell you that the changes have been made, and I will advise all others who need to know about the change(s) to your PHI.
F. The Right to Get This Notice by Email. You have the right to get this notice by email. You have the right to request a paper copy of it, as well.
V. HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If, in your opinion, I may have violated your privacy rights, or if you object to a decision I made about access to your PHI, you are entitled to file a complaint with the person listed in Section VI below. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue, S.W., Washington, DC. 20201. If you file a complaint about my privacy practices, I will take no retaliatory action against you.
VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If you have any questions about this notice or any complaints about my privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me at: Dale Ellis, Ph.D., PO Box 5645, Walnut Creek, CA 94596. Or,(925) 943-1137. Or, daleellis@sbcglobal.net
VII. EFFECTIVE DATE OF THIS NOTICE: This notice went into effect on April 14, 2003.
I acknowledge receipt of this notice:
Patient Name (PRINT): _____________________Date:______
Signature:_____________________
Patient Name (PRINT):_____________________ Date:_______
Signature_______________________
Patient Name (PRINT): ____________________ Date: _______
Signature: _____________________
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CONSENT TO USE OR DISCLOSE INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS (TPO)
Patient Name: ___________________________ :
Federal regulations (HIPAA) allow me to use or disclose Protected HealthInformation (PHI) from your record in order to provide treatment to you, to obtain payment for the services we provide, and for other professional activities (known as "health care operations."). Nevertheless, I ask your consent in order to make this permission explicit. The Notice of Privacy Practices describes these disclosures in more detail. You have the right to review the Notice of Privacy Practices before signing this consent. We reserve the right to revise our Notice of Privacy Practices at any time. If we do so, the revised Notice will be available from this office. You may ask for a printed copy of our Notice at any time. You may ask us to restrict the use and disclosure of certain information in your record that otherwise would be disclosed for treatment, payment, or health care operations; however, we do not have to agree to these restrictions. If we do agree to a restriction, that agreement is binding. You may revoke this consent at any time by giving written notification. Such revocation willl not affect any action taken in reliance on the consent prior to the revocation. This consent is voluntary; you may refuse to sign it. However, we are permitted to refuse to provide health care services if this consent is not granted, or if the consent is later revoked. I hereby consent to the use or disclosure of my Protected Health Information as specified above.
Signature of Patient: _____________________
Date: ___________ |
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DIRECTIONS TO OFFICE:
COMING FROM THE NORTH ON 680, get off at the South Main exit. Turn left and go underneath the Freeway.
TURN RIGHT AT CREEKSIDE DR. (the first signal light).
Go up the hill a little ways and turn left at Quail Court Offices. There is a building up on the hill, on the right. The next three buildings are #33, #35, and #37. I am in office 102 in Building #37. The office is on the ground floor on the side of the building you are on. There is no waiting room so please wait until your appointment time (there is a bench to sit on), and then knock on the door if I have not already opened it for you.
COMING FROM THE SOUTH ON 680, get off at the South Main Street exit. The first signal light is Creekside Dr. Turn right on Creekside Dr. and follow the directions as described above beginning right after "TURN RIGHT AT CREEKSIDE DR."
COMING THROUGH TOWN FROM THE NORTH, go south on South Main street, past Newall, the Kaiser Medical Center on your right, Los Lomas High School on your left, and then you will come to a signal light at Creekside Dr. Turn left at Creekside, and follow the directions above after "TURN RIGHT AT CREEKSIDE DR."
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