Patient Name:___________________________________________________________________________________

                                                          PRIVACY PRACTICES POLICY:

What Information Is Protected

1. Information your doctors, and other health care providers put in your medical record 2.Conversations your therapist has about your care or treatment with others 3.Information about you in your health insurer’s computer system 4.Billing information about you at your clinic 5.Most other health information about you held by those who must follow these laws.
Health Insurers and Providers who are covered entities must comply with your right to:
 
1.Ask to see and get a copy of your health records 2.Have corrections added to your health information
3.Receive a notice that tells you how your health information may be used and shared 4.Decide if you want to give your permission before your health information can be used or shared for certain purposes, such as for marketing 5.Get a report on when and why your health information was shared for certain purposes 6.If you believe your rights are being denied or your health information isn’t being protected, you can file a complaint with your provider, health insurer or the U.S. Government.

To make sure that your health information is protected in a way that does not interfere with your health care, your information can be used and shared:

1.For your treatment and care coordination 2.To pay doctors and hospitals for your health care and to help run their businesses 3.With your family, relatives, friends, or others you identify who are involved with your health care or your health care bills, unless you object 4.To make sure doctors give good care and nursing homes are clean and safe 5.To protect the public's health, such as by reporting when the flu is in your area 6.To make required reports to the police, such as reporting gunshot wounds.

Acknowledgement of Privacy Practices Policy:
I acknowledge that I am aware of QCCounselor’s Notice of Privacy Practices . I understand that QCCounselor has the right to revise these information practices and to amend the Notice of Privacy Practices. I understand that in the event that the Notice is revised, the revised Notice will be posted at QCCounselor and I understand that I may obtain a current Notice of Privacy Practices at any time from the office manager at QCCounselor

________________________________________________________________________________________________ _________________
Signature of Patient/Parent/ Guardian/Representative                                                                                                             Date

______________________________________________________________________________ ____________________________________
Printed name                                                                                                                                        Relationship to patient

Patient’s Agreement to be Treated and to be Financially Responsible:
I acknowledge that the patient or other responsible party is responsible for payment of fees unless otherwise agreed upon. I further understand that I may be charged for any missed appointments or for appointments that are cancelled without 24 hour notice. I also understand that failure to meet the financial obligations related to my appointments and charges may result in disruption of service and/or being the subject of legal action
.
I give my consent to be treated at QCCounselor.

I authorize QCCounselor to release information necessary for billing only to my insurance company and/or financially responsible party. I authorize QCCounselor to release treatment plans necessary for authorization to my insurance company. I also authorize QCCounselor to release information to the referring individual or organization and to my family physician. I further acknowledge and authorize that my records may be anonymously reviewed by other members of QCCounselor staff for the purpose of treatment review and crisis management. I direct the insurer to pay, without equivocation, directly to QCCounselor all benefits due as a result of my scheduled visits or charges.
 

________________________________________________________________________________________________ _________________
Signature of Patient/Parent/Guardian/Representative                                                                                                                Date

 

Form: qcc12