This notice describes how medical/mental health information about you, and/or your child, may be used or disclosed and how you can get access to this information. Please review it carefully.

Whole Child Therapy must maintain the privacy of your health information and to provide you with this notice. You will be asked to sign a Release of Information Form. Once you have signed the Release of Information Form, Whole Child Therapy staff members may use or disclose your Protected Health Information (PHI) for purposes of diagnosis, treatment, obtaining payment, or to conduct healthcare operations. For example, to receive payment for our services, Whole Child Therapy must provide information to the funding source being used. Other permitted and required uses and disclosures that may be made without your consent, authorization, or opportunity to object:

Abuse or Neglect: If any Whole Child Therapy member suspects abuse or neglect of a child and elder, he/she is mandated to make a report to the appropriate public authorities.

Danger: If a Whole Child Therapy staff member suspects that you are in imminent danger of harming yourself or someone else, he/she is mandated to make a report to the person at risk to the public authorities.

Legal Proceedings: Whole Child Therapy staff members may disclose PHI in response to a court order or subpoena or certain other legal proceedings.

You have the following rights regarding PHI Whole Child Therapy maintains about you.

Right to Inspect and Copy: You have the right to inspect and request copies of information that may be used to make decisions about your care. Usually, this includes demographic and billing records but does not include case notes. To inspect and receive copies of information, you must submit a request in writing. If you request a copy of the information, Whole Child Therapy may charge a fee for the cost of copying, mailing, or other supplies associated with your request. Whole Child Therapy must respond to your request within fifteen days of receipt.

Right to Amend: If you feel that PHI about you is incorrect or incomplete, you may ask Whole Child Therapy to amend the information. You have a right to request an amendment for as long as Whole Child Therapy keeps the information. Your request for amendment must be in writing and must provide a reason supporting your request.

Right to an Accounting of Disclosures: You have the right to request an Accounting of Disclosures regarding information that Whole Child Therapy staff members have made about you. You must submit your request in writing to the above address. Your request must state a period for the disclosures, which may not be longer than six years and may not include dates before July 1, 2011.

Right to Request Restrictions on Uses and Disclosures: You may request that disclosure of confidential information be limited. If Whole Child Therapy is unable to agree to that restriction, we can discuss other options, such as referral to another counselor.

Right to Limit Reception of Confidential Information: For example, you may request that Whole Child Therapy staff members only contact you at a certain telephone number or address. You do not have to give a reason for your request.

Right to a Paper Copy of this Notice of Privacy Practices: You have a right to a paper copy of this signed notice.

Other uses and disclosure of PHI and any disclosure of Case Notes will be made only with your written authorization. After such authorization is given, you may revoke that authorization at any time from future use. This notice may be amended as needed to comply with federal, state, and professional requirements.

Notice of Privacy Practices Receipt Form

I, the undersigned, have read and received a copy of the Notice of Privacy Practices from the staff of Whole Child Therapy.