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Health Insurance Portability Accountability Act (HIPAA)
Client Rights & Therapist Duties

This document contains important information about federal law, the Health Insurance Portability
and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to
the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment,
payment, and health care operations.

HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and
disclosure of PHI for treatment, payment and health care operations. The Notice, explains HIPAA
and its application to your PHI in greater detail.

The law requires that I obtain your signature acknowledging that I have provided you with this. If
you have any questions, it is your right and obligation to ask so I can have a further discussion prior
to signing this document. When you sign this document, it will also represent an agreement between
us. You may revoke this Agreement in writing at any time. That revocation will be binding unless I
have taken action in reliance on it.

LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communication between a patient and a therapist. In most
situations, I can only release information about your treatment to others if you sign a written
authorization form that meets certain legal requirements imposed by HIPAA. There are some
situations where I am permitted or required to disclose information without either your consent or
authorization. If such a situation arises, I will limit my disclosure to what is necessary. Reasons I
may have to release your information without authorization:

1. If you are involved in a court proceeding and a request is made for information concerning
your diagnosis and treatment, such information is protected by the psychologist-patient
privilege law. I cannot provide any information without your (or your legal representative's)
written authorization, or a court order, or if I receive a subpoena of which you have been
properly notified and you have failed to inform me that you oppose the subpoena. If you are
involved in or contemplating litigation, you should consult with an attorney to determine
whether a court would be likely to order me to disclose information.

2. If a government agency is requesting the information for health oversight activities, within its
appropriate legal authority, I may be required to provide it for them.

3. If a patient files a complaint or lawsuit against me, I may disclose relevant information
regarding that patient in order to defend myself.

4. If a patient files a worker's compensation claim, and I am providing necessary treatment

5. I may disclose the minimum necessary health information to my business associates that
perform functions on our behalf or provide us with services if the information is necessary
for such functions or services. My business associates sign agreements to protect the privacy
of your information and are not allowed to use or disclose any information other than as
specified in our contract.
There are some situations in which I am legally obligated to take actions, which I believe are
necessary to attempt to protect others from harm, and I may have to reveal some information about a
patient's treatment:

1. If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or
neglected by a parent, legal custodian, caregiver, or any other person responsible for the
child's welfare, the law requires that I file a report with the Iowa Abuse Hotline. Once such
a report is filed, I may be required to provide additional information.

2. If I know or have reasonable cause to suspect, that a vulnerable adult has been abused,
neglected, or exploited, the law requires that I file a report with the Iowa Abuse Hotline.
Once such a report is filed, I may be required to provide additional information.

3. If I believe that there is a clear and immediate probability of physical harm to the patient, to
other individuals, or to society, I may be required to disclose information to take protective
action, including communicating the information to the potential victim, and/or appropriate
family member, and/or the police or to seek hospitalization of the patient.

CLIENT RIGHTS AND THERAPIST DUTIES

Use and Disclosure of Protected Health Information:

• For Treatment – I use and disclose your health information internally in the course of your
treatment. If I wish to provide information outside of our practice for your treatment by
another health care provider, I will have you sign an authorization for release of information.
Furthermore, an authorization is required for most uses and disclosures of psychotherapy
notes.

• For Payment – I may use and disclose your health information to obtain payment for services
provided to you as delineated in the Therapy Agreement.

• For Operations – I may use and disclose your health information as part of our internal
operations. For example, this could mean a review of records to assure quality. I may also
use your information to tell you about services, educational activities, and programs that I
feel might be of interest to you.

Patient's Rights:

• Right to Treatment – You have the right to ethical treatment without discrimination regarding
race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other
protected category.

• Right to Confidentiality – You have the right to have your health care information protected.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share
that information for the purpose of payment or our operations with your health insurer. I will
agree to such unless a law requires us to share that information.

• Right to Request Restrictions – You have the right to request restrictions on certain uses and
disclosures of protected health information about you. However, I am not required to agree
to a restriction you request.

• Right to Receive Confidential Communications by Alternative Means and at Alternative

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI.
Records must be requested in writing and release of information must be completed.
Furthermore, there is a copying fee charge of $1.00 per page. Please make your request well
in advanced and allow 2 weeks to receive the copies. If I refuse your request for access to
your records, you have a right of review, which I will discuss with you upon request.

• Right to Amend – If you believe the information in your records is incorrect and/or missing
important information, you can ask us to make certain changes, also known as amending, to
your health information. You have to make this request in writing. You must tell us the
reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I
will tell you why within 60 days.

• Right to a Copy of This Notice – If you received the paperwork electronically, you have a
copy in your email. If you completed this paperwork in the office at your first session a copy
will be provided to you per your request or at any time.

• Right to an Accounting – You generally have the right to receive an accounting of disclosures
of PHI regarding you. On your request, I will discuss with you the details of the accounting
process.

• Right to Choose Someone to Act for You – If someone is your legal guardian, that person can
exercise your rights and make choices about your health information; I will make sure the
person has this authority and can act for you before I take any action.

• Right to Choose – You have the right to decide not to receive services with me. If you wish, I
will provide you with names of other qualified professionals.

• Right to Terminate – You have the right to terminate therapeutic services with me at any time
without any legal or financial obligations other than those already accrued. I ask that you
discuss your decision with me in session before terminating or at least contact me by phone
letting me know you are terminating services.

• Right to Release Information with Written Consent – With your written consent, any part of
your record can be released to any person or agency you designate. Together, we will discuss
whether or not I think releasing the information in question to that person or agency might be
harmful to you.

Therapist’s Duties:

• I am 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. I reserve the right to change the
privacy policies and practices described in this notice. Unless I notify you of such changes,
however, I am required to abide by the terms currently in effect. If I revise my policies and
procedures, I will provide you with a revised notice in office during our session.

COMPLAINTS

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made
about access to your records, you may contact me, the State of Iowa Department of Health, or the
Secretary of the U.S. Department of Health and Human Services.
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND
AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU
HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.

________________________________________________ ________________
Client/Legal Guardian Signature Date

________________________________________________
Printed Name

________________________________________________ ________________
Client/Legal Guardian Signature Date

________________________________________________
Printed Name

________________________________________________ ________________
SLP Signature, Credentials Date

________________________________________________
Printed SLP Name, Credentials

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