Mojgan Jahan, Psy.D., Clinical Psychologist, PSY 19101
Notice of Privacy Practices
This notice involves your privacy rights and describes how information about you may be disclosed, and how you can obtain access to this information. Please review it carefully
As a rule, I will disclose no information about you, or the fact that you are my client, without your written consent. I will keep a mental health record which describes the services provided to you in general terms, the dates of our sessions, and billing/payment information as well as Psychotherapy Notes.
Psychotherapy Notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
Psychotherapy notes may not be disclosed without your authorization except in certain limited circumstances:
- Use or disclosure in supervised mental health training programs for students, trainees, or practitioners;
- Use or disclosure by the covered entity to defend a legal action or other proceeding brought by the individual;
- A use or disclosure that is required by law
A use or disclosure that is permitted:
o for legal and clinical oversight of the psychotherapist who made the notes,
o to prevent or lessen a serious and imminent threat to the health or safety of the public
In order for a medical provider to release “Psychotherapy Notes” to a third party, the client who is the subject of the Psychotherapy Notes must sign an authorization to specifically allow for the release of Psychotherapy Notes. Such authorization must be separate from an authorization to release other medical records.
II. “Limits of Confidentiality”
Possible Uses and Disclosures of Mental Health Records without Consent or Authorization
There are some important exceptions to confidentiality required by law. We will discuss these issues now, but you may reopen the conversation at any time during our work together.
I may use or disclose records or other information about you without your consent or authorization in the following circumstances in accordance to my own policy or because legally required:
· Emergency If you are involved in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.
· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by
· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by law to make a report and provide relevant information to Adult Protective Services.
· Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order.
· Serious Threat to Health or Safety: Under the law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization.
In addition to above, please be advised that if we work together via telephone or other electronic means, privacy problems may arise with broadcast conversations (e.g., overheard wireless phone conversations or captured Internet transmissions).
· Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations — You have the right to request and receive confidential communications of
· Right to an Accounting of Disclosures – You generally have the right to receive an accounting of disclosures of
. Right to Inspect and Copy- You have the right, which may be restricted only in exceptional circumstances, to inspect and copy
· Right to Amend – If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
· Right to a copy of this notice – You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Changes to this notice: I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date. I will have copies of the current notice available on request.
· Complaints: If you believe your privacy rights have been violated, you may file a complaint with me and/or submit a written complaint to
o Board Of Psychology
Patient’s Acknowledgement of receipt of Notice of Privacy Practices
Please sign, print your name, and date this acknowledgement form.
I have been provided a copy of Dr. Jahan’s Notice of Privacy Practices. I understand that I may ask questions about them at any time in the future.
Printed Name: ___________________________________________________________________