CONSENT FOR SERVICES:
I hereby give permission to mentalhealthhookup.com to provide services to me as requested.
These services may include:
- Information & Referrals
- Individual Therapy
- Group Therapy
- Case Management
- Money Management
- Crisis Intervention
- Placement Services
- Family Treatment Services
- Custody Evaluations
Other Services within the purview of mental health community practitioners as requested by me.
I understand that all communication between me and MentalHealthHookup is both privileged and confidential. This means the counselor/therapist cannot discuss my case orally or in writing without my express written permission.
- Supervision and/or peer counseling:
Supervision of staff and/or peer counseling is required to assure that quality care is being provided to you. When this occurs, all personal identification markers deleted (name, address, telephone, social security number etc) is deleted.
- Legal Proceedings: We may disclose your protected health information for law enforcement purposes, as long as applicable legal requirements are met. These law enforcement purposes include, but are not limited to, (a) legal processes required by law, (b) limited information requests for identification and location purposes, (c) information pertaining to victims of a crime, (d) suspicion that death has occurred as a result of criminal conduct.
- We will contact you to the best of our ability to discuss such requests with you.
- Abuse or Neglect: We may disclose your protected health information to a public health authority which is authorized by law to receive reports of child abuse or neglect or elder abuse or neglect. We may disclose your protected health information to the appropriate designated authorities. Additionally, we may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. In such cases, the disclosure will be made consistent with the requirements of applicable federal, state and local laws.
- Research projects with Personal identification markers deleted: Personal Identification Markers are specific information about you as a person such as your name, address, social security number, etc.
- Public Health Authorities:
Public Health Authorities may require disclosure of your protected health information for public health activities and purposes to control disease, injury, or disability. We may also disclose your protected health information to a foreign government agency that is collaborating with the public heath authority, when directed by the public health authority.
- Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
- Health Oversight:
We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
- Other Involved in Your Health Care:
Unless you object, we may use or disclose health information to notify, or assist in the notification of a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of emergency circumstances or your incapacity to agree or object, we will disclose protected health information based on a determination using our professional judgement, disclosing only health information that is directly relevant to the person’s involvement in your healthcare and only that which is in your best interest. We may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
- Marketing Health-Related Services:
We will NOT use your health information for marketing communication.
- Law Enforcement:
We may disclose your protected health information for law enforcement purposes, as long as applicable legal requirements are met. These law enforcement purposes include, but are not limited to: (l)legal processes required by law, (2)limited information requests for identification and location purposes, (3)information pertaining to victims of a crime, and (4)suspicion that death has occurred as a result of criminal conduct.
- Coroners, Funeral Directors, & Organ Donation:
We may disclose your protected health information to a coroner or medical examiner for identification purposes, determining cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose your protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his-her duties. We may disclose your protected health information in reasonable anticipation of death for organ or tissue donation purposes.
- National Security & Military Activity:
We may disclose your protected health information to military authorities or Armed Forces personnel when appropriate conditions apply. We may disclose, to authorized state and federal officials, health information required for lawful intelligence, counterintelligence, and national security activities. We may also disclose protected health information for the determination of benefits eligibility through the Department of Veteran Affairs and to foreign military authorities, if you are a member of that foreign military service. We may disclose your protected health information to a correctional institution or law enforcement officials if we are directed to do so by proper authorities if you are an inmate of a correctional facility.
- Appointment Reminders:
We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, letters, or e-mails)
You have a right to Inspect & Copy your files. This includes your own medical & billing records, but does not include psychotherapy notes. Upon proof of an appropriate legal relationship, records of others related to you or under your care (guardian, conservator) may also be disclosed.
To inspect & copy your medical record, please submit your request in writing . We may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may DENY your request to inspect & copy in certain very limited circumstances. Should that occur, another licensed health care professional chosen by our Practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome and recommendations from that review.
- Right To Amend:
If you feel that the information we have about you in your record is incorrect or incomplete, then you may ask us to amend the information, following the procedure below:
The request must be submitted in writing, along with your intended amendment and a reason that supports your request to amend. The amendment must be dated and signed by you. It should be notarized.
- Right To An Accounting of Disclosures:
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you, to others.
- Right To An Accounting of Disclosures:
You have the right to request a restriction or limitation on information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care (e.g. a family member, friend)
We are not required to agree to your request and we may not be able to comply with your request. If we do agree, we will comply with your request except that we shall not comply, even with a written request, if the information is excepted from the consent requirement or we are otherwise required to disclose the information by law.
- To Request Restrictions, You must:
(a) Make your request in writing (b) Indicate the information you want to limit (c) Whether you want to limit our use, disclosure or both, and (d) To whom you want the limits to apply (e.g. disclosures to your children, spouse, parents, etc)
- Right to Request Confidential Communications:
You have the right to request that we communicate with you about your issues in a certain way or certain location. For example, you can ask that we only contact you at work or by mail, or by e-mail etc.
To request confidential communications, you must make your request in writing. We will not ask you the reason for your request. Your request must specify how you wish us to contact you. We accommodate all reasonable requests.
- You have a right to a paper copy of this notice.
Please notice that you are required to print a copy of this notice electronically. You are still entitled to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.
DISCLAIMER:Please be clear that when MentalHealthHookup.com refers you, the caller, to a resource, we are NOT guaranteeing that you will get satisfaction---Only that this is a resource that appears to be appropriate given your stated problems.
We do value your feedback, however, and would like to know the quality of your experience. Additionally, Mental Health Hookup.com may contact you for follow-up to see what your level of satisfaction both with our service and their experience with the referrals.