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Terms and Policy

HIPAA Statement (effective June 18, 2018)

HIPAA NOTICE OF PRIVACY PRACTICES

Effective Date: June 18, 2018

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. 
OUR OBLIGATIONS: 
We are required by law to :

Maintain the privacy of protected healthcare information
Give you this notice of our legal duties and privacy practices regarding health information about you.
Follow the terms of our notice that is currently in effect.

You may request a copy of this Notice from the therapist, or you can view a copy of it in the office or on the website, which is located at www.angelasarafin.com.

HOW WE WILL USE AND DISCLOSE YOUR PHI
The following describes the ways we may use and disclose health information that identifies you ("Health Information"). Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer. 
Consenting to treatment authorizes the following disclosures: 

FOR TREATMENT. We may use and disclose Health Information for your treatment and to provide you with related services. We may disclose your Health Information 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, we may disclose your PHI to her/him in order to coordinate your care. 

FOR PAYMENT. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment. We could also provide Health Information to business associates, such as billing companies, debt collections agencies, claims processing companies, and others that process claim payments for my office.

FOR HEALTH CARE OPERATIONS. We may disclose Health Information to facilitate the efficient and correct operation of the practice. Examples: Quality control - we might use Health Information 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. We may also provide Health Information to our attorneys, accountants, consultants, and others to make sure that we are in compliance with applicable laws. Health Information may also be shared for the purposes of training and supervising our staff and providing backup care in the care of your therapist's absence.

APPOINTMENT REMINDERS, TREATMENT ALTERNATIVES, and HEALTH RELATED BENEFITS and SERVICES. We may use and disclose Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you. 

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE. When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort. 

RESEARCH. Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information. 

SPECIAL SITUATIONS WHERE USED AND DISCLOSURE DO NOT REQUIRE YOUR CONSENT: 
EMERGENCIES. Your consent is not required if you need emergency treatment provided that we attempt to get your consent after treatment is rendered. In the event that we try to get your consent but you are unable to communicate with us (for example, if you are unconscious or in severe pain) but we think that you would consent to such treatment if you could, we may disclose your Health Information.

AS REQUIRED BY LAW. We will disclose Health Information when required to do so by international, federal, state or local law. This includes mandatory reporting when we see evidence of, are told about, or suspect abuse, neglect, or endangerment of children, elderly, or disabled persons. This also includes mandatory reporting if we are informed that another licensed counselor has engaged in sexual activity with a client.

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat. 

BUSINESS ASSOCIATES. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

MILITARY AND VETERANS. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military. 

WORKERS' COMPENSATION. We may release Health Information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. 

PUBLIC HEALTH RISKS. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

HEALTH OVERSIGHT ACTIVITIES. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

DATA BREACH NOTIFICATION PURPOSES. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

LAWSUITS AND DISPUTES. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information 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 or to obtain an order protecting the information requested. 

LAW ENFORCEMENT. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person's agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. 

CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties. 

NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. 

PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations. 

INMATES OR INDIVIDUALS IN CUSTODY. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.

CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT: 
INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

DISASTER RELIEF. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES
The following uses and disclosures of your Protected Health Information will be made only with your written authorization:
1. Uses and disclosures of Protected Health Information for marketing purposes; and
2. Disclosures that constitute a sale of your Protected Health Information

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation. 

YOUR RIGHTS:
You have the following rights regarding Health Information we have about you:
Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to Angela Sarafin, LMFT, LPC (Records Manager). We are not required to give you access directly to our records management system as that would potentially compromise the privacy of other clients. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

Please note that records more than 5 years old may have been destroyed per allowance in Texas and DC records retention laws.

RIGHT TO AN ELECTRONIC COPY OF ELECTRONIC MEDICAL RECORDS. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request within 15 days, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

RIGHT TO GET NOTICE OF A BREACH. You have the right to be notified upon a breach of any of your unsecured Protected Health Information. If the breach affects more than 500 people, a general notice will be made via local media and on our website.

RIGHT TO AMEND. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request (including the reason for the request), in writing, to Angela Sarafin, LMFT, LPC (Records Manager). You will receive a response within 60 days of our receipt of your request. We may deny your request, in writing, if we find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of our records, or (d) written by someone who is no longer associated with this company. Our 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 a copy of the denial be attached to any future disclosures of your Health Information. If we approve your request, we will make the change(s) to your Health Information. Additionally, we will tell you that the changes have been made, and will advise all others who need to know about the change(s) to your Health Information.

RIGHT TO AN ACCOUNTING OF DISCLOSURES. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Angela Sarafin, LMFT (Records Manager). We will respond to your request for an accounting of disclosures within 60 days of receiving your request.

RIGHT TO REQUEST RESTRICTIONS. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to Angela Sarafin, LMFT, LPC (Records Manager). We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us "out-of-pocket" in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Out-of-Pocket-Payments. If you paid out-of-pocket in full (or in other words, you have requested that we not bill your health plan) for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request. You may choose to not use your insurance even if your insurance plan would otherwise cover the services requested.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to your therapist and/or Angela Sarafin, LMFT, LPC (Records Manager). Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests. 

RIGHT TO A PAPER COPY OF THIS NOTICE. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, www.angelasarafin.com. To obtain a paper copy of this notice, you may either download and print a copy from the website or you may ask your therapist for a copy. Please note that due to the location of the printer/copier, your therapist may not have a paper copy available during your session, but will make arrangements to have a copy available as soon as is reasonably possible.

CHANGES TO THIS NOTICE:
We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page, in the top right-hand corner.

COMPLAINTS:
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. 

To file a complaint with our office, contact Angela Sarafin, LMFT, LPC, info@angelasarafin.com or submit written complaints by mail or in person at the office where you received services.

If you believe that a therapist has behaved in an unethical or illegal manner, you may file a complaint with the Licensing board in the state where you received services.

District of Columbia Licensing Board: (202) 442-5955
Complaint forms available at http://doh.dc.gov/service/file-complaint-health%20prof


All complaints must be made in writing. You will not be penalized for filing a complaint.

( Type Full Name )
Consent to Treat and Fee Schedule
This is to inform you of basic information and policies regarding the counseling relationship, including the rights, responsibilities, and expectations for both parties.

FEES AND CANCELLATION POLICY

As of September 2018, the session fee is $210 per 50-minute session and $300 per 75-minute session.  This rate applies to new clients and returning clients (if it has been more than 60 days since your last appointment you are considered a returning client).


Scheduling presents a challenge for the private counselor. Once a time has been agreed upon, that time is unavailable to others, and is difficult to reassign on short notice. For this reason, we ask you to cancel your appointment as soon as you know you will not be coming. Late cancellations will be billed to the card on file.


To avoid being charged the full fee for your appointment, please give 2 days notice before your appointment is scheduled (ie: if your appointment is on Monday at 11am, you must cancel by 11am on the preceding Saturday; if it is Wednesday at 9am, cancel by Monday at 9am). Exceptions will be made for emergencies. Please call your counselor for cancellations of less than 48 hours.


Cancellation with at least 48 hours notice may be accomplished through the client portal or by calling the therapist.  Please do not cancel via email or text message as timely message delivery cannot be guaranteed.  If you do cancel via text or email, the arrival time of the message will be used to determine whether the late cancellation fee is due.


Standard sessions are 50 minutes in length. Longer sessions may be scheduled as appropriate.  The session fee is due at time of service. You may pay by cash, credit card, HSA card, or check (made payable to Angela Sarafin, LMFT).


CONFIDENTIALITY

The effectiveness of counseling is based on a trusting relationship between client and counselor. As your counselors, we are committed to maintaining strict confidentiality about anything shared with us. This includes all verbal and written contact both during counseling and after the counseling relationship has ended.
The only exceptions to this are:
1. Where there is cause to suspect a child, adolescent, disabled person, or vulnerable older person has been abused or neglected.
2. Where there is reasonable cause to believe that you pose risk of imminent harm to yourself.
3. Where there is reasonable cause to believe that you pose risk of imminent harm to others.
4. When a valid court order compels the use of our records or testimony.
5.  When you have given written consent to disclose information to another person or party.
Regarding couples, family or group therapy, each of the clients (or guardians if the client is under 18) must, in writing, waive confidentiality before any records or information can be released. Your counselor does not take responsibility for the disclosure that others may make.


RELEASE OF LIABILITY

In signing this form, I acknowledge that I am receiving counseling from Angela Sarafin, LMFT. In consideration of the benefits to be derived from my counseling, I hereby release and forever discharge and covenant not to sue or hold legally liable Angela Sarafin, LMFT or any counselors or staff employed by them.

I understand that counseling comes with no warranty, guarantee, or promise of any particular result, that counseling can be difficult, and that it may lead to discomfort and dealing with difficult emotions. By agreeing to receive counseling, I assume any risk of pain or distress that may arise as a result of the counseling process. 

I hereby waive any right I may otherwise have to seek to use the record of my counseling as evidence in any judicial proceeding or to compel the testimony of my counselor in any such proceeding. If this waiver is breached, I will pay a penalty of $500 plus any and all administrative and legal charges incurred by the counselor and will pay for time the counselor spends responding to the subpoena regardless of whether the counselor actually appears for any deposition or court hearing.

I CONSENT TO PARTICIPATE IN COUNSELING AND AGREE TO ABIDE BY THE POLICIES AND PROCEDURES OUTLINED ABOVE.


I UNDERSTAND MY RIGHTS AND RESPONSIBILITIES AS A CLIENT AND MY COUNSELOR'S RESPONSIBILITIES TO ME.


I AGREE TO PAY FOR SERVICES IN FULL AT THE TIME OF THE APPOINTMENT OR PRIOR, AND UNDERSTAND THAT I WILL BE CHARGED THE FULL SESSION FEE IF I FAIL TO SHOW OR PROVIDE LESS THAN 48 HOURS NOTICE OF CANCELLATION.


I AGREE TO HAVE MY CARD ON FILE CHARGED UNLESS I PROVIDE ANOTHER METHOD OF PAYMENT AT THE BEGINNING OF MY APPOINTMENT.

( Type Full Name )