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Wichita Therapy Center

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360

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Policies and Practices to Protect the Privacy of Your Health Information

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%3cdiv contenteditable%3d%27false%27 unselectable%3d%27on%27 class%3d%27unselectable%27%3ePolicies and Practices to Protect the Privacy of Your Health Information

HIPAA and CONFIDENTIALITY INFORMATION
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I.	Uses and Disclosures for Treatment%2c Payment%2c and Health Care Operations

Effective/Last Revised Date%3a  June 15%2c 2008	
Consultation and Counseling is required by federal law to protect the privacy of your health information in the context of your mental health and substance abuse health care administered by this agency.  We are also required to send you this notice%2c which explains how we may use information about you and when we can give out or “disclose” that information to others.  You also have rights regarding your health information that are described in this notice.

The terms “information” or “health information” in this notice include any personal information that is created or received by a health care provider that relates to your physical or mental health or condition%2c the provision of health care to you%2c or the payment for such health care.

We have the right to change our privacy practices.  If we do%2c we will provide the revised notice to you within 60 days by direct mail or post it in our agency office or on the website.

We may use or disclose your protected health information %28PHI%29%2c for treatment%2c payment%2c and health care operations purposes with your consent. To help clarify these terms%2c here are some definitions%3a
•	“PHI” refers to information in your health record that could identify you.
•	“Treatment%2c Payment and Health Care Operations”
— Treatment is when we provide%2c coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider%2c such as your family physician or another Therapist. Another example would be when we release your treatment plan to your insurance company and/or to your primary care physician.
— Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
— Health Care Operations are activities that relate to the performance and operation of my practice. Examples of healthcare operations are quality assessment and improvement activities%2c business-related matters such as audits and administrative services%2c and case management and care coordination.
•	“Use” applies only to activities within our %5boffice%2c clinic%2c practice group%2c etc.%5d such as sharing%2c employing%2c applying%2c utilizing%2c examining%2c and analyzing information that identifies you.
•	“Disclosure” applies to activities outside of our %5boffice%2c clinic%2c practice group%2c etc.%5d%2c such as releasing%2c transferring%2c or providing access to information about you to other parties.

II.	Uses and Disclosures Requiring Authorization

HOW WE USE OR DISCLOSE INFORMATION
We must use and disclose your health information to provide information%3a
To you or someone who has the legal right to act for you %28your personal representative%29%3b
To the Secretary of the U.S. Department of Health and Human Services%2c if necessary%2c to ensure that your privacy is protected%3b and 
Where required by law.

We may use or disclose PHI for purposes outside of treatment%2c payment%2c or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we asked for information for purposes outside of treatment%2c payment or health care operations%2c we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes we have made about your conversation during a private%2c group%2c joint%2c or family counseling session%2c which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations %28of PHI or Psychotherapy Notes%29 at any time%2c provided each revocation is in writing. You may not revoke an authorization to the extent that %281%29 we have relied on that authorization%3b or %282%29 if the authorization was obtained as a condition of obtaining insurance coverage%2c law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

We have the right to use and disclose health information to pay for your health care and operate our business.  For example%2c we may use your health information%3a

To process claims for health care services you receive.
For Treatment.  We may disclose health information to your doctors or hospitals to help them provide medical care to you.
For Health Care Operations.  We may use or disclose health information as necessary to operate and manage our business and to help manage your health care coverage.  For example%2c we might talk to your doctor to suggest a disease management or wellness program that could help improve your general health.
To Provide Information on Health Related Programs or Products such as alternative medical treatments and programs or about health related products and services.
To Referral Sources.  If you are referred through another agency such as your Primary Care Physician%2c Juvenile Court%2c DFCS%2c Psychiatric Hospital%2c CMHC%2c etc.%2c we may share summary information and admission and discharge information with the referral source.  In addition%2c we may share other health information with the referral source for case management purposes if the referral source agrees to special restriction on its use and disclosure of the information.
For Appointment Reminders.  We may use health information to contact you for appointment reminders with providers who provide medical or mental health care to you.

We may use or disclose PHI without your consent or authorization in the following circumstances under limited circumstances%3a
To Persons Involved With Your Care.  We may use or disclose your health information to a person involved in your care%2c such as a family member%2c when you are incapacitated or in an emergency%2c or when permitted by law. 
For Public Health Activities such as reporting disease outbreaks.
For Reporting Victims of Abuse%2c Neglect or Domestic Violence to government authorities%2c including social service or protective service agencies. If we have reasonable cause to believe that a child has been abused%2c we must report that belief to the appropriate authority. If we have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person%2c other than by accidental means%2c or has been neglected or exploited%2c we must report that belief to the appropriate authority.
For Health Oversight Activities such as governmental audits and fraud and abuse investigations. If we are the subject of an inquiry by the Georgia Composite Board%2c we may be required to disclose protected health information regarding you in proceedings before the Board.
For Judicial or Administrative Proceedings such as in response to a court order%2c search warrant or subpoena. If you arc involved in a court proceeding and a request is made about the professional services we provide you or the records thereof%2c such information is privileged under state law%2c and we will not release information without your written consent%2c subpoena or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
For Law Enforcement Purposes such as providing limited information to locate a missing person.
Serious Threat to Health or Safety. If we determine%2c or pursuant to the standards of my profession should determine%2c that you present a serious danger of violence to yourself or another%2c we may disclose information in order to provide protection against such danger for you or the intended victim.
For Specialized Government Functions such as military and veteran activities%2c national security and intelligence activities%2c and the protective services for the President and others.
For Workers Compensation including disclosures required by state workers compensation laws relating to job-related injuries. We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs%2c established by law%2c that provide benefits for work-related injuries or illness without regard to fault.
For Research Purposes such as research related to the prevention of disease or disability%2c if the research study meets all privacy law requirements.
To Provide Information regarding Decedent%27s.  We may disclose information to a coroner or medical examiner to identify a deceased person%2c determine a cause of death%2c or as authorized by law.  We may also disclose information to funeral directors as necessary to carry out their duties.
For Organ Procurement Purposes.  We may use or disclose information for procurement%2c banking or transplantation of organs%2c eyes or tissue.
If a use or disclosure of health information is prohibited or materially limited by other applicable law%2c it is our intent to meet the requirements of the more stringent law.

If none of the above reasons applies%2c then we will obtain your written authorization to use or disclose your health information.  If a use or disclosure of health information is prohibited or materially limited by other applicable law%2c it is our intent to meet the requirements of the more stringent law.  In some states%2c your authorization may also be required for disclosure of your health information.  In many states%2c your authorization may be required in order for us to disclose your highly confidential health information%2c as described below.  Once you have given us authorization to release your health information%2c we cannot guarantee that the person to whom the information is provided will not disclose the information.  You may take back or “revoke” your written authorization%2c except if we have already acted based upon your authorization.  To revoke an authorization%2c contact the phone number listed below on this notice.

HIGHLY CONFIDENTIAL INFORMATION
Federal and applicable state laws may require special privacy protections for highly confidential information about you.  “Highly confidential information” may include confidential information under Federal law governing alcohol and drug abuse information as well as state laws that often protect the following types of information%3a
HIV/AIDS%3b
Mental health%3b
Genetic tests%3b
Alcohol and drug abuse%3b
Sexually transmitted diseases and reproductive health information%3b and 
Child or adult abuse or neglect%2c including sexual assault.

IV.	Patient’s Rights and Therapist’s Duties

Patient’s Rights%3a
•	Right to Request Restrictions — You have the right to request restrictions on certain uses and disclosures of protected health information. However%2c we are not required to agree to a restriction you request.
•	Right to Receive Confidential Communications by Alternative Means and at Alternative Locations — You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. %28For example%2c you may not want a family member to know that you are seeing therapists. On your request%2c we will send your bills to another address.%29
•	Right to Inspect and Copy — You have the right to inspect or obtain a copy %28or both%29 of PHI in your mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances%2c but in some cases you may have this decision reviewed. On your request%2c we will discuss with you the details of the request and denial process. Your therapist may also deny access to your Psychotherapy Notes.
•	Right to Amend— You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request%2c we will discuss with you the details of the amendment process.
•	Right to an Accounting — You generally have the right to receive an accounting of disclosures of PHI. On your request%2c we will discuss with you the details of the accounting process.
•	Right to a Paper Copy — You have the right to obtain a paper copy of the notice from us upon request%2c even if you have agreed to receive the notice electronically.

Therapist’s Duties%3a
•	We are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
•	We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes%2c however%2c we are required to abide by the terms currently in effect.
•	If we revise these policies and procedures%2c we will notify you by mail or on your next session. You may obtain a copy of this notice at the local office or website.

V.	Complaints
Contacting _______________________________________________.  If you have any questions about this notice or want to exercise any of your rights%2c please call 845-473-4939.  Please specify that your question or concern is in reference to your mental health and/or substance abuse protected health information.
Filing a Complaint.  If you believe your privacy rights have been violated%2c you may file a complaint with us at the following address%3a
Compliance Department – Privacy Complaints

1. Sending a letter to 200 Independence Avenue%2c S.W.%2c Washington%2c D.C. 20201%3b  
2. Calling 1-877-696-6775%3b or%2c
3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint.  We will not take any adverse action against you for filing a complaint.

VI. Cancellation Policy
In the Event of an emergency%2c you will not be charged for session cancellation. Cancellations for any other reasons that are not received by clinic staff at least 24 hours prior to the scheduled session will be billed at the session rate. Your insurance company will not pay for missed appointments.

VII. Financial Responsibility
__________________________________________________will assist you in completing and filing any insurance forms%2c which may be utilized for payments for services%3b however%2c you maintain full responsibility for paying all charges for services rendered. You will need to provide all required insurance information when checking in for services and you will need to update any changed insurance information immediately upon the date of change. All co-payments and unsatisfied deductibles are to be paid at the time of services rendered.  does accept payment by cash or check.
 
VIII. Effective Date%2c Restrictions%2c and Changes to Privacy Policy
This notice will go into effect on October 1%2c 2006. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain.

IX. Patient’s Consent
I consent for my therapist to disclose my protected health information %28PHI%29 as required by my insurance company. Furthermore%2c if my insurance company requires coordination of care with my Primary Care Provider %28PCP%29%2c I consent for my therapist to disclose my protected health information to my PCP. I have read this statement of.’s practices and policies and I both understand and approve of its content.

%3c/div%3e

Date: I have read and I agree to the Policies and Practices to Protect the Privacy of Your Health Information

Electronic Signature of Client or Legal Guardian:

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Wichita Therapy Center

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. What would your partner say?

5. Length of these relationship:

6. Can you tell me a little bit about yourself and your family/culture/upbringing?

7. Can you tell me a little bit about what intimate relationships look like for you?

8. Do you have any dependents?

9. Therapy before:

10. Psychiatry before:

11. Medications (type & dosage frequency):

12. Alcohol and Drug Use (type & dosage frequency):

Describe use:

13. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

14. Recreational drugs: Yes No

Describe use:

15. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

16. Self Harming Behaviours: Yes No

Describe, including most recent incident:

17. Violence Towards Others: Yes No

Describe, including most recent incident:

18. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

19. Experience of life being threatened by person, accident, or natural disaster: Yes No

20. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

21. Actions taken concerning above risks:

22. Religious Affiliation/Denomination:

23. Occupation:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. City Year Employee: (site name, site grade level, & program manager):

27. Availability:

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee: Insurance and/or Sliding scale amount:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

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Wichita Therapy Center

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360

Intake

1. Occupation:

Youth worker:

No describe

Yes describe

2. If City Year Employee: (site name, site grade level, & program manager):

3. How did you hear about us?

4. What type of therapy are you seeking? Individual Couples Family Hybrid Group

5. What brings you in?

6. Client stated strengths

7. Can you tell me a little bit about yourself and your family/culture/upbringing?

8. Tell me a little bit about your community & social supports

9. Do you have any dependents?

10. Therapy before:

11. Psychiatry before:

12. Medications (type & dosage frequency):

13. Alcohol and Drug Use (type & dosage frequency):

Describe use:

14. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

15. Recreational drugs: Yes No

Describe use:

16. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

Access to any weapons, if so type:

17. Self Harming Behaviours: Yes No

Describe, including most recent incident:

18. Violence Towards Others: Yes No

Describe, including most recent incident:

19. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

20. Experience of life being threatened by: Person Accident Natural Disaster

21. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

22. Actions taken concerning above risks:

23. Religious Affiliation/Denomination:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. Availability:

27.Insurance and/or Sliding scale amount:

Everything below is for Office Staff Only to Complete

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

32. Youth worker: Yes No

33. Describe if not occupation (under occupation)

Secure Site

Wichita Therapy Center

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

5. Violence Towards Others: Yes No

Describe, including most recent incident:

6. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

7. Client Informed of Fee: Insurance and/or Sliding scale amount:

8.Client Notes

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Wichita Therapy Center

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360

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Secure Site

Wichita Therapy Center

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360

Intake

Intake Question

Referral Source

Are you currently on active duty? Yes No

Military Branch

Highest Level of Education

Employment status

Are you currently enrolled in school or job training program?

Are you currently using? Yes No

Routine of administration types:

During the past 30 days, how many days have you used any of the following:

Cocaine/crack

Marijuana/Hashish

Heroine

Morphine

Dilaudid

Demerol

Fentanyl

Percocet

Darvon

Codeine

Tylenol 2, 3, 4

OxyContin/Oxycodone

Non-prescription methadone

Hallucinogens/psychedelics, PCP, LSD, Mushrooms, or Mescaline

Methamphetamine or other amphetamines

During the past 30 days, how many days have you used any of the following:

Benzodiazepines: diazepam, alprazolam, Triazolam, and etizolam

Barbiturates: Metharbital and pentobarbital sodium

Non-prescription GHB

Ketamine

Other tranquilizers, downers sedatives, or hypnotic

Inhalants

Other illegal drugs

Drug of Choice-Diagnosis

Behavioral Health

Children's Services Referral Yes No

If Children's Services referral, do you have an active Children's Services case? Yes No

# of children that you have

Crime Justus status

Probation Yes No

Parole Yes No

PROB 45 Yes No

Human Trafficking

Is there a history of Sexual Abuse?

Program Placement (Level of Care)

Sober Housing Needed Yes No

Sober Housing Provided Yes No

Medical Intake Questions

If female, are you pregnant? Yes No

Medicated Assisted Treatment (MAT)

Hypertension

Diabetes

STI's

UTI's

Cellulitis

COPD

Asthma

Blood dyscrasia

City

State

Zip code

County

Is there a history of drug use? Yes No

In the past 30 days, where have you been living most of the time?

Are you currently employed?

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Notes

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Electronic Signature

Wichita Therapy Center

807 N. Waco Suite 11 Wichita KS 67203 316-776-4360

PRIMARY CLIENT INFORMATION

PARTNER INFO

PRIMARY INSURED

Primary Insurance Information

SECONDARY INSURED ("If Applicable")

Wichita Therapy Center

807 N. Waco Suite 11 Wichita KS 67203 316-776-4360

Wichita Therapy Center

807 N. Waco Suite 11 Wichita KS 67203 316-776-4360

Wichita Therapy Center

807 N. Waco Suite 11 Wichita KS 67203 316-776-4360

Wichita Therapy Center

807 N. Waco Suite 11 Wichita KS 67203 316-776-4360

Wichita Therapy Center

807 N. Waco Suite 11 Wichita KS 67203 316-776-4360

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360

807 N. Waco Suite 11
Wichita KS 67203
316-776-4360