Client Notification of Privacy Rights

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The Health Insurance Portability and Accountability Act (HIPAA) ensures client protections surrounding the use of Protected Health Information (PHI). Commonly referred to as the “medical records privacy law”, HIPAA provides patient protections related to the electronic transmission of data (“the transaction rules”), the keeping and use of patient records (“privacy rules”), and storage and access to health records (“the security rules”). HIPAA applies to all health care providers including mental health. Providers of health care throughout the country are required to provide patients with a notification of their privacy rights as it relates to their healthcare records. You have already received similar notices such as this one from your other health care providers. As you might expect, the HIPAA law and regulations are extremely detailed. My Client Notification of Privacy Rights is my attempt to inform you of your rights in a simple yet comprehensive fashion. Please read this document, as it is important that you know what patient protections HIPAA affords all of us. In mental healthcare confidentiality and privacy are central to the success of the therapeutic relationship. You will find that I will do all I can do to protect the privacy of your mental health records. If you have any questions about any matters discussed in this document, please do not hesitate to ask me for further clarification. By law, I am required to secure your signature indicating that you have received this Client Notification of Privacy Rights Document. A copy of the HIPAA document is located in the second section of this document following your signature below. I also keep a copy in a white binder in my waiting area if you wish to review it at any time. Thank you for your thoughtful consideration of these matters.
Julie L. Brown, LPC, MHSP

I____________________________ understand and have been provided a copy of Julie L. Brown, LPC, MHSP’s Notice of Privacy Practices Document which provides a detailed description of the potential uses and disclosures of my Protected Health Information, as well as my rights in these matters for my review. I understand I have the right to review this document before signing this acknowledgment form and I acknowledge that I have received a personal copy. (Please type your name below.) *

Signature

Your signature below signifies that you understand the terms of this agreement and consent to follow these terms throughout our work together. Typing your name below serves as your signature and indicates your agreement to abide by the terms of this Client Notification of Privacy Rights document.

Type your name below to sign. *

Please indicate the date of your signature below. *

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