Notice of Counselor’s Policies and Practices to
Protect the Privacy of Your Health 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, Payment, and Health Care Operations
We may use or disclose your protected health information (PHI), for treatment, payment, and health care
operations purposes with your consent. To help clarify these terms, here are some definitions:
• “PHI” refers to information in your health record that could identify you.
• Treatment is when we provide, 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 such as your family physician or another psychologist.
• 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 our practice.
Examples of health care operations are quality assessment and improvement activities, business
matters such as audits and administrative services, and case management and care coordination.
• “Use” applies only to activities within our [office, clinic, practice] such as sharing, employing, applying,
utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of our [office, clinic, practice], such as releasing, transferring,
or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, 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 are asked for information
The Psychology Clinic Adult Intake Form 12
for purposes outside of treatment, payment or health care operations, 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 our conversations during a
private, group, joint, or family counseling session, which we have kept separate from the rest of your
medical record. These notes are given more protection than PHI.
You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided that each
revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that
authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage.
Law provides the insurer the right to contest the claim.
III. Uses and Disclosures with Neither Consent nor Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances:
• Child Abuse – If we have reasonable cause to believe that a child has been abused, we must report
that belief to the appropriate authority.
• Adult and Domestic Abuse – 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, other
than by accidental means, or has been neglected or exploited, we must report that belief to the
• Health Oversight Activities – If we are the subjects of an inquiry by the Georgia Board of Professional
Counselors, we may be required to disclose protected health information regarding you in proceedings
before the Board.
• Serious Threat to Health or Safety – If we determine, or pursuant to the standards of our profession
should determine, that you present a serious danger of violence to yourself or another, we may
disclose information in order to provide protection against such danger for you or the intended victim.
I have read the above and understand that it is my responsibility to make sure all insurance requirements
are fulfilled. It is also my responsibility to notify this office of any changes in my insurance. I agree to be
responsible for all charges incurred with The Psychology Clinic that result from non-covered services or
client’s failure to meet insurance requirements