Raven Counseling HIPAA & Privacy Policies

This agreement describes how your health information may be used and disclosed, and how you can get access to this information. Please review it carefully.

During the course of your treatment, your provider may gather information about you and your therapeutic treatments, medical history, and health for purposes of providing therapeutic services to you. Raven Counseling recognizes and appreciates that information about you and your health is personal and private. Information that identifies you and relates to your past, present, and future physical or mental health is referred to as your Protected Health Information (“PHI”). We are committed to protecting such information from improper use and disclosure. Raven Counseling is required to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices. This Agreement describes the ways in which your PHI may be used or disclosed and your rights to access and control your PHI.

Use and Disclosure of Your Protected Health Information

Except in the specific circumstances set forth below, the confidentiality of your PHI will be maintained and only shared with your written permission. If you grant written permission for your PHI to be shared, you may change your mind and revoke permission at any time, in writing. You understand that any disclosures I have already made with your permission are unable to be taken back, and that it is required to retain records of the care that was provided to you. In the following circumstances, your PHI may be used and disclosed without your written consent.

For Treatment

Your PHI may be used and disclosed to provide you with therapy and any related services. For example, only with your consent, your PHI may be disclosed to other doctors, nurses, technicians, or other personnel, who are involved in taking care of you and need the information to provide you with medical care. As a healthcare professional, your provider may also seek consultation with other mental health providers regarding your treatment as a standard part of practice. Each of these healthcare providers must maintain the confidentiality of your PHI. Your provider will always act to protect your privacy and disclose as little information as possible.

You may also be sent appointment reminders or informed about treatments and health-related benefits or services that you may find helpful. When transmitting information regarding your care electronically (for example, faxing information) it will be done with special safeguards to ensure confidentiality. If you elect to communicate with your provider by email during the duration of the therapeutic relationship, be aware email communication may not be secure. If you email your provider from your work email, please be advised that your company owns your emails and can read any correspondence. Therapeutic issues should not be discussed through email and email, phone and text correspondence is encouraged to be limited to scheduling and other administrative concerns. If you choose to communicate with your provider via email or text/phone, you are releasing your provider and Raven Counseling of liability associated with any privacy violations that may occur through these means of communication. Secure and HIPAA compliant messaging through the Simple Practice portal is available, which may be a better means of communicating more sensitive personal information.

For Payment & Billing

Your PHI may be used and disclosed so that the treatment and services you receive may be billed to and payment collected from you, an insurance or health managed care company, Medicare, Medicaid or another third-party payer. For example, share dates you received therapy, diagnosis, treatment plans and progress notes may be shared with your insurance company in order to receive payment. Your insurance company may also be informed about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

To Avert a Serious Threat to Health or Safety.

Your PHI may be used and disclosed when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat (police, the specific person you intend to harm etc.) More specifically:

1. If there is reason to believe you will harm another person, it is your provider’s legal obligation to attempt to warn the person who is at risk of your intentions, or unable to make contact with the potential victim, your provider is obligated to contact the appropriate authorities and ask them to protect the intended victim.

2. If there is reason to believe you are physically, sexually or emotionally abusing or neglecting a child or vulnerable adult, or if you give specific information about another individual who is, your provider must inform the appropriate authorities (police, child protection or adult protection).

3. If there is reason to believe you are in imminent danger of harming yourself, or unwilling to take steps to guarantee your safety, your provider is obligated to inform the appropriate authorities and, in certain circumstances, your emergency contact or other member of your family or treatment team. The county crisis team or police may be called to transport you to a local hospital for a full psychological assessment.

4. If your provider is informed of a pregnant woman who is using illegal substances, misusing prescription medications, or misusing alcohol, they must inform the appropriate authorities.

5. If you inform a provider of another named health or mental health care provider who is engaging in the following behaviors it is their ethical duty to report this information to the appropriate licensing board(s): (a) engaging in sexual contact with a patient, including you; or (b) is impaired from practice in some manner such as, cognitive, emotional, behavioral, or health problems.

Lawsuits, Probation, and Disputes.

If you are involved in a lawsuit or a dispute, your PHI may be disclosed in response to a court or administrative order. It may also be disclosed in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request to allow you to obtain an order protecting the information requested. Furthermore, if subpoenaed, your provider will contact their liability insurance attorneys to learn what information must legally be provided, if any.

If you are receiving court-ordered services or fulfilling terms of probation or parole, your probation officer or the courts may request information or records regarding services. Information will not be released unless I receive written consent from you. However, if your provider receives a court order requesting records they must comply with this order. They will only disclose the information requested and will do their best to advocate for your confidentiality.

Law Enforcement/Required by Law

Health information may be released under certain circumstances if asked to do so by a law enforcement official, federal, state, or local law. (again, attorneys will always be consulted before releasing information).

For Health Care Operations.

Your PHI may be used or disclosed in order to support Raven Counseling’s business activities and health care operations. These uses and disclosures are necessary to run the business and make sure that patients receive quality care. Your PHI will never be sold or released for marketing purposes.

Family and Couples Therapy

Generally, if you and your co-participant(s) in therapy participate in individual sessions as part of the relational therapy session, what you report in those individual sessions is considered part of the relational therapy sessions and may be discussed in joint sessions. Do not disclose anything you wish to keep confidential from your partner or family members in these individual sessions. You will be reminded of this policy at the beginning of individual sessions related to family or couple’s therapy. Further, if you invite another person to participate in your therapy session, some information related to your sessions may be shared as part of the therapy session. *Please note that each individual provider may vary on their “secrets” policy as a part of couples or family therapy. Please speak with your individual provider about their specific Family/Couples Therapy informed consent/policies.

Minors in Therapy (also see and complete “minor assent form”)

If you are a minor, your parents may be legally entitled to some information about your therapy. Your provider will discuss with you and your parent(s) or guardian(s) what information is appropriate for them to receive and which issues are more appropriately kept confidential.

Please note, if you are using a parent or legal guardian’s insurance policy, they will be able to see diagnosis and services billed through their health insurance provider.

Custody Evaluations

Not all therapists are qualified to conduct custody evaluations.  If you are needing this service, it is your responsibility to discuss this with your therapist, however, they reserve the right to deny this request based on qualifications. Additional fees may apply for appearing in court, writing court documents and assessments, and travel/parking.

Client Rights and Responsibilities

Right to Request Restrictions.

You have the right to request restrictions on the PHI used or disclosed about you for treatment or payment. You also have the right to request restrictions on the PHI disclosed about you to a family member, close personal friend, or other person involved in your health care or the payment of your care. For example, you could ask that information about a particular diagnosis not be shared with your spouse. You can request that information about a service not be sent to your insurer and instead choose to pay for services out of pocket. Your provider is not required to agree to other requests if it is not feasible for them to ensure compliance or believe it will negatively impact the care provided to you. If they do agree, they will comply with your request unless the information is needed to provide you emergency treatment or as otherwise required by law. To request a restriction, you must make your request in writing to your provider. In your request, you must state what information you want to limit and to whom you want the limits to apply. You understand that your provider is unable to take back any disclosures they have already made with your permission, and that they are required to retain records of the care that they provided to you.

Right to Request Confidential Communications.

Normally, your provider will communicate with you at the address, phone number and email you provide. You have the right to request your provider to communicate with you in other ways or at another location. For example, you can ask that they only contact you at work or by mail to a post office box.  Reasonable requests will be accommodated.

To request confidential communication, you must make your request in writing to your provider. Your request must specify how or where you wish to be contacted. Simple Practice does have a HIPAA compliant secure “messaging” platform you are welcome to use to contact your provider with more confidential concerns.

Raven Counseling and your provider cannot guarantee the confidentiality and security of any information that is shared electronically, specifically via email or by text message.

Maintenance of Records.

Providers are required by their board(s) to maintain records of therapy sessions. Common information provided in notes include the date, time, and duration of each session, which interventions were used and the general outline of topics discussed. Treatment plans for each client are required and your provider should collaborate with you about your treatment goals and ask you to sign a copy of your treatment plan. These are reviewed and updated regularly. Creating a treatment plan is best practice, frequently required by insurance companies and most boards. Your records are kept in the HIPAA compliant Simple Practice electronic medical record system. Please speak with your provider if you have questions or concerns about documentation requirements.

Right to Access/Inspect and Copy.

You have the right to look at or get copies of your PHI. If you request a copy of your electronic health record or other health information that is kept electronically, it will be provided in the form or format you request, if it is readily producible in such form or format. If your PHI is not readily producible in the form or format you request, your record will be provided in either my standard electronic format or, if you do not want this form or format, in a readable hard copy form. You must make your request in writing to your provider. If you ask for hard copies, you may be charged a reasonable fee for copying and mailing your requested information. If you ask for another format available, you may be charged a reasonable fee. Your request to inspect or receive copies of your records may be denied in certain limited circumstances. If your request is denied, a denial letter will be sent in writing, which will include the reason and describe any rights you may have to a review of the denial. Your provider has the right to refuse to provide you with a copy of your records if it is their clinical opinion that it would be detrimental to your mental health.

Health Records under State Law.

Release of health records by licensed Minnesota providers usually requires the signed permission of the patient or the patient’s legal representative. Exceptions include medical emergencies, and other releases required or allowed by law.

Right to Amend.

You may ask your provider to amend certain parts of your protected health information. Your request must be made in writing and you must explain why the information should be changed. If your provider accepts your change request, attempts to inform prior recipients will be made, including people you list in writing, of the change. If your request for amendment is denied, you will be given a written denial letter including the reasons for the denial and the right to submit a written statement disagreeing with the denial.

Right to an Accounting of Disclosures.

You have the right to request a list accounting for any disclosures of your PHI that have been made, except for uses and disclosures for treatment, payment and health care operation, as previously described. To request this list of disclosures, submit your request in writing to your provider. Your request must state a time period which may not be longer than seven years and may not include dates before April 14, 2003. If you ask for a list more than once in a 12-month period, you may be charged a fee for each extra list. You will be notified of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to a Paper Copy of This Notice.

You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from me in writing.

Right to Receive Notice of a Breach.

You have a right to be notified upon a breach of the privacy of your PHI and will be provided with such notice promptly.

Changes to this Agreement

Raven Counseling reserves the right to change the terms of this agreement, and to make the revised or changed notice provisions effective for PHI already obtained about you as well as any information that may receive in the future. You will be provided with a copy of any changes made to this agreement.

If you believe your privacy rights have been violated and wish to file a complaint, you may do so with the US Department of Health and Services for Civil Rights by sending a letter to 200 Independence Ave SW, Washington DC 20201 or by calling 1-877-696-6775 or visiting http://www.hhs.gov/ocr/privacy/hipaa/complaints/. Raven Counseling and your provider understands these rights and will not retaliate against you for filing a complaint.

Acknowledgement of Receipt of HIPAA Notice of Privacy Practices

By signing this form, I acknowledge I have received a copy of Raven Counseling’s HIPAA Notice and Privacy Practices and that I fully understand and consent to these practices. I understand I can revoke this consent in writing which will stop the future use of PHI, however, PHI disclosed prior to this cannot be changed. I understand that if Raven Counseling’s privacy practices changed, I will be notified of this change.

BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT