Family Ministries Center Confidentiality Agreement
Please read this consent form carefully as it is essential for your understanding of your privacy rights. Information divulged by you or your child, and psychotherapist and clinic records about you or your child will be held in strict confidence. Information and records will not be released to anyone outside the clinic without your written permission on a separate authorization form. However, the following exceptions are either mandated by law or are usual practices at a psychological services clinic.
1. Statements you or your child make of an intention to commit suicide or homicide, if assessed by your psychotherapist as a realistic threat, will be reported to the proper authorities (e.g., the police, the potential victim, family members) to prevent the suicide or homicide attempt.
2. If in the course of psychotherapy it has been uncovered that there is child or elder abuse-where a child or elder is threatened harm, is in imminent danger, or has been recently harmed-a report will be made to the proper authorities (e.g., Child Protective Services, the care-givers, and the police).
3. Information necessary for your or your child’s health will be released to facilitate treatment in a medical emergency or for identification purposes in case of death.
4. All information and records about you or your child will be released to other psychotherapists within Family Ministries Center to facilitate professional consultations about your or your child’s case. Records are also available to the clinic’s administrative assistant, medical billing service manager, accountant, and practice management service manager so that they can fulfill their duties.
5. All court ordered subpoenas (not lawyer office requests) asking for your or your child’s records, or for information about you or your child for a deposition or courtroom testimony, will be released.
6. Information necessary for processing your or your child’s insurance claim will be released. If your insurance company is not managed care, then information released is usually limited to identifying information, diagnosis, and dates and type of service. If the insurance company is managed care, then information released can be extensive – including symptoms, types of treatment interventions, treatment goals and plans, medication use, assessment results, functional status, progress, prognosis, as well as diagnosis and dates and type of service. However, you have the right to privacy, which means you can choose not to consent to releasing information to your insurance company and instead pay cash for your psychological treatment and assessment (excluding Tricare beneficiaries).
7. Information or records about your child (under 18 years of age) will be released to parents or legal guardians if requested. Information will only we withheld if it threatens the child’s safety. Teenagers may also have the right to privacy regarding obtaining assessment and education of issues pertaining to sex, pregnancy, drugs or alcohol, if it is state law.
8. Information or records about your spouse will be released to you if it is in the course of marital psychotherapy where you are both being seen by the same psychotherapist. However, if you are presently separated, divorced, legally pursuing divorce, or if the spouse specifically requests that certain information remains confidential, then information of records will not be divulged.
9. Review of records by enforcement agencies to show compliance to the law regarding patient privacy and proper file keeping.
You have the right to receive a copy of records about yourself only if you sign a release and pay for the copies. You also have the right to make, and have attached, amendments to your records. You also have the right to know when and what information about you or your records were released to persons or agencies outside this clinic. However, you do not have the right to change, erase, or remove information contained neither in your records; nor do you have the right to dictate what your psychotherapist writes or doesn’t write about you in your records, nor do you have the right to access your psychotherapist’s session (progress) notes.
The psychotherapists and staff at the Family Ministries Center try to be as discreet as possible when contacting you (by telephone, mail, e-mail, etc). However, if you do not wish that people contact your home or workplace to possibly infer that you are seeing a psychotherapist, then you need to inform your psychotherapist of this so that other arrangements can be made about how to contact you.
Please discuss with your psychotherapist any questions or concerns you have about the above.
All Family Ministries Center services conform to the latest HIPAA (The Health Insurance Portability and Accountability Act) guidelines.