The confidentiality of your medical records and treatment is your privilege exclusively. Since this is your privilege, we will ask you to sign a “Release of Confidentiality” form prior to releasing any information that is requested. Your confidentiality is so important whether another treatment agency or an individual who is planning to pick you up is inquiring about you, your information will not be released unless there is a signed, current release on file.
Your records and information about your treatment services belong to you. Only you or your legally authorized representative has the right to request access to your treatment information. If at any time, you or your legally authorized representative would like a copy of your records you simply need to let me know. I will ask you to sign a “Release of Confidentiality” indicating the release of copies of your records to you as this is required by law.
The information available to persons or agencies actively engaged in your treatment is limited to the minimum amount of information necessary for that person or agency to carry out what is needed for you or to complete what is needed based upon a release that you have authorized.
Services are not contingent upon your decision concerning authorization for the release of information and you will never be threatened or coerced to provide consent; your authorization is a voluntary decision.
After receiving a request for confidential information, I will respond within fifteen (15) days from the date of receipt of the request to furnish all documents requested. I will make every attempt to explain the benefits and disadvantages of releasing information (if known) prior to the information being released.
As part of my practice, I complete process improvement projects to improve my services. Plus, in the search for increased funding and sources of funding, I use information for statistical purposes based on treatment services provided. Any consumer information and/or data I use for research or reporting purposes will in no manner identify you, unless you have given me authorization to do so.
You may revoke your consent by signing the area indicated on the consent form identifying your desire to revoke the consent. If you are unable to come to the office, you may do this verbally by phone; you will be asked at that time to come to the office at the earliest possible time to sign the revocation.
Conditions do exist in which I will, however, release your information without your permission for example if you are having a medical or psychiatric emergency; if child abuse, neglect or exploitation is suspected; if elderly abuse is suspected; if a court or tribunal order, subpoena, or search warrant is issued pursuant to 42 CFR; if an arrest warrant is provided; or, if you have committed a crime against me or any of my employees.