YOUR RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION
I am required by law to furnish you with information about my professional credentials as well as your rights regarding privacy of your record here. No part of your healthcare record will be disclosed to any other person or entity without your signed consent either via this Authorization and Consent for Treatment, or through a specific signed Consent for Release of Confidential Information with Wyoming Art Therapy & Medical Counseling LLC. The only exceptions to this are listed below:
1. A court order directly to Andrea A Berry, MHR, ATR-BC, LPC, NCC
2. An emergency exists in which your safety or the safety of others is threatened or questioned.
3. In compliance with the laws protecting children and the elderly from abuse.
4. In answer to a licensing body regarding any complaint of malpractice.
5. Guardians or legal custodians are the persons that sign consent and authorization for any client under the age of 18.
You have the right to request to inspect, copy, or amend your protected health information. This is granted if no harm exists in such sharing, and with the understanding that Wyoming Art Therapy & Medical Counseling LLC and Andrea Berry are not responsible for any re-disclosure of such information after it is shared with you. Any amendments requested require the agreement of Pendley & Associates and Andrea A Berry and in the case that is not granted you may file a statement of disagreement which may be rebutted. You must make all your requests in writing. All copies of records will be charged a fee of $.25/per page. You have the right to identify where you would like any communication from me sent, and by what means you prefer to have your information shared (i.e. fax, letter, verbally, etc.) You have the right to receive an accounting of any disclosures made.
Your case may be discussed in professional counsultation for the benifit of your care and treatment. Your privacy and confidentiality will be maintained at all times.
NEED TO KNOW:
· A counseling appointment is 50 minutes long unless specifically designated otherwise.
- Under no circumstances is it appropriate or ethical for a counselor or client to have any type of sexual relationship.
- Under no circumstances is it appropriate for a client and counselor to have additional business agreements in which barter or trade for services occur.
Clients and counselors shall strive to avoid “dual relationships” in which they interact for business, social or other activities away from the counseling setting, for a period of 2 years following termination of services. If two “regularly set appointments are missed without” notice the time slot will be given away and no further appointments will be set until this counselor is contacted by the client.
· To have your confidentiality maintained at all times, unless there is an explicit concern of harm to self or others. (Duty to warn)
· To be treated with respect and dignity
· A safe, sanitary, and humane treatment environment that protects you from harm or abuse
· Services and referrals without discrimination as to race, age, gender, marital status, religion, sexual orientation, national origin, degree of disability, political belief, legal status, and/or the ability to pay for services
· To Participate in treatment planning and consent or refusal of such services unless these rights are abridged by law or emergency situation
· To know of any research being done, and to refuse participation in any research
· To assert grievances and not to be retaliated against for exercising any of these rights
You may revoke this authorization at any time in writing, except to the extent that Andrea Berry has already disclosed or taken action relying upon your consent within this authorization.