HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R.
Parts 160 and 164)
The Health Insurance Portability and Accountability Act (HIPAA) establishes patient rights and
protections associated with the use of protected health information. HIPAA provides patient
protections related to the electronic transmission of data (“the transaction rules”), the keeping
and use of patient records (“privacy rules”), and storage and access to health care records (“the
security rules”). HIPAA applies to all health care providers, including mental health care
providers. Providers and health care agencies are required to provide patients a notification of
their privacy rights as it relates to their health care records.
This Patient Notification of Privacy Rights informs you of your rights. Please carefully read this
Patient Notification. It is important that you know and understand the patient protections HIPAA
affords you as a patient.
In mental health care, confidentiality and privacy are central to the success of the therapeutic
relationship; therefore, I will do all we can do to protect the privacy of your mental health
records. If you have questions regarding matters discussed in this Patient Notification, please
do not hesitate to ask.
I. Preamble
Records are kept documenting your care as required by law, professional standards, and other
review procedures. HIPAA clearly defines what kind of information is to be included in your
“designated medical record” or “case record” as well as some material, known as
“Psychotherapy Notes” which is not accessible to insurance companies and other third-party
reviewers. HIPAA provides privacy protections about your personal health information, which is
called “protected health information (PHI)” which could personally identify you. PHI consists of
three (3) components: treatment, payment, and health care operations.
Treatment refers to activities/sessions I provide, coordinate or manage your mental health care
service or other services related to your health care. Examples include a counseling session or
communication with your primary care physician about your medication or overall medical
condition.
Payment is when Elyse Etapa, LLC obtains reimbursement for your mental health care or other
services related to your health care.
Health care operations are activities related to my performance such as quality assurance. The
use of your protected health information refers to activities my agency conducts for scheduling
appointments, keeping records, and other tasks related to your care. Disclosures refer to
activities you authorize such as the sending of your protected health information to other parties
(i.e., your insurance company).
II. Uses and Disclosures of Protected Health Information Requiring Authorization
If you request Thrive Counseling Service to send any of your protected health information of any
sort to anyone outside my office, you must first sign a specific authorization to release
information to this outside party. A copy of that authorization form is available on the website
and upon request. In recognition of the importance of the confidentiality of conversations
between therapist and patients in treatment settings, HIPAA permits keeping “psychotherapy
notes” separate from the overall “designated medical record”. “Psychotherapy notes” are the
therapist’s notes “recorded in any medium by a mental health provider documenting and
analyzing the contents of a conversation during a private, group, or joint family counseling
session and that are separated from the rest of the individual’s medical record.” “Psychotherapy
notes” are private and contain information about you and your treatment.
III. Uses and Disclosures Not Requiring Consent or Authorization
By law, protected health information may be released without your consent or authorization
under the following conditions:
• Suspected or known child abuse or neglect
• Suspected or known sexual abuse of a child
• Adult and Domestic abuse
• Judicial or administrative proceedings (i.e. you are ordered here by the court)
• Serious threat to health or safety (i.e. “Duty to Warn” and Threat to National Security)
V. Patient’s Rights and Our Duties
You have a right to the following:
• The right to request restrictions on certain uses and disclosures of your protected health
information which I may or may not agree to but if I do, such restrictions shall apply unless our
agreement is changed in writing
• The right to receive confidential communications by alternative means and at alternative
locations. For example, you may not want forms mailed to your home address so I will send
them to another location of your choosing.
• The right to inspect and copy your protected health information in the designated record and
any billing records for as long as protected health information is maintained in the record.
• The right to insert an amendment in your protected health information, although the therapist
may deny an improper request and/or respond to any amendment(s) you make to your record of
care.
• The right to an accounting of non-authorized disclosures of your protected health information.
• The right to a paper copy of notices/information from Thrive Counseling Services, even if you
have previously requested electronic transmission of notices/information.
• The right to revoke your authorization of your protected health information except to the extent
that action has already been taken.
For more information on how to exercise each of these aforementioned rights, please do not
hesitate to ask for further assistance on these matters.
Thrive Counseling Services is required by law to maintain the privacy of your protected health
information and to provide you with a notice of your Privacy Rights and our duties regarding
your PHI. Thrive Counseling Services reserves the right to change its privacy policies and
practices as needed with these current designated practices being applicable unless you
receive a revision of these policies when you come for future appointment(s). Our duties in
these matters include maintaining the privacy of your protected health information, to provide
you with a notice of your rights and our privacy practices with respect to your PHI, and to abide
by the terms of the notice unless it is changed and you are so notified.
VI. Complaints
The right to have oral or written instructions for filing a grievance. The right to file a grievance is
not time limited. If you need assistance in filing a grievance or want further information, please
contact:
Ohio Department of Mental Health
Eight Floor, Rhodes State Office Tower
30 East Broad Street
Columbus, OH 43266-0414
(330) 264 - 2527
OR
Mental Health and Recovery Services Board of Stark County
121 Cleveland Avenue SW
Canton, OH 44702
(330) 455 - 7424
Please print, sign, and date this form below to acknowledge that you have familiarized yourself
with Confidentiality/HIPAA practices.
I __________________________________________________________________,
(Patient/Guardian if a minor), have either downloaded or have been provided a copy of The
Patient Notification of Privacy Rights.
My signature below indicates that I had opportunity to review this document prior to signing it.
Patient/Guardian Signature:_____________________________________________________
Date: __________________________
Therapist Signature: ___________________________________________________________
Date: __________________________