This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. You have the right to:

 

 Get a copy of your paper or electronic medical record  Correct your paper or electronic medical record

 Request confidential communication

 Ask us to limit the information we share

 Get a list of those with whom we've shared your information  Get a copy of this privacy notice

 Choose someone to act for you

 File a complaint if you believe your privacy rights have been violated

You have some choices in the way that we use and share information as we may:  Tell family and friends about your condition

 Provide disaster relief

 Include you in a hospital directory  Provide mental health care

 Market our services and sell your information  Raise funds

 

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. To get an electronic or paper copy of your medical record

 

You can ask us to correct health information about you that you think is incorrect or incomplete

 We may say ''no" to your request, but we'll tell you why in writing within 60 days  Ask us to connect your medical record

  You can ask us to correct health information about you that you think is incorrect or incomplete

 We may say ''no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications

 You can ask us to contact you in a specific way or to send mail to a different address  We will say ''yes" to all reasonable requests

 Ask us to limit what we use or share

 You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.

 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. We will say "yes" unless a law requires us to share that information.

 You may request for a list of those with whom we've shared information

 You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.

 We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).

 We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

 

Get a copy of this privacy notice

You can ask for a paper copy of this notice of any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

 

Choose someone to act for you

 If you have given act someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

  We will make sure the person has this authority and can for you before we take any action.

 

File a complaint if you feel your rights are violated

 You can complain if you feel we have violated your rights by contacting us using the information on our "Contact Us" website page www.soundwellnesstelepsychiatry.com or via email at soundwellnesstelepsyc@gmail.com

 You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.

 We will not retaliate against you for filing a complaint.

For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us.

In these cases, you have both the right and choice to tell us to:

 Share information with your family, close friends, or others involved in your care  Share information in a disaster relief situation

 If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

We typically use or share your health information to in the following ways: To treat you

 To share your information with other professionals who are also treating you  Run our organization

 Improve your care and contact you when necessary  Bill for your services

 Address workers' compensation, laws enforcement, and other government requests

 Help with public health, research, and safety issues such as: Preventing disease o Helping with product recalls; Reporting adverse reactions to medications; Reporting adverse reactions to medications; Reporting suspected abuse, neglect, or domestic violence; Preventing or reducing a serious threat to anyone's health or safety; Comply with law; and we can share health information with a coroner, medical examiner, or funeral director when an individual die We can use or share health information about you:

 For workers' compensation claims

 For law enforcement purposes or with a law enforcement official  With health oversight agencies for activities authorized by law

 For special government functions such as military, national security, and presidential protective services

 Respond to lawsuits and legal actions

 We can share health information about you in response to a court or administrative order, or in response to a subpoena

 We are required by law to maintain the privacy and security of your protected health information

 We will let you know promptly if a breach occurs that may have compromised the privacy or security of — your information

 We must follow the duties and privacy practices described in this notice and give you a copy of it

 We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Your signature on this form confirms your consent to mental health services to be rendered to you or a person for whom you are a legal representative or are a legal guardian (Power of Attorney). The details of such mental health services have been explained to you as well as the risks and benefits of treatment, of alternative treatments, and of no treatment at all. You also understand there is NO GUARANTEE that any particular result will be achieved.

 

DO NOT SIGN THE FORM IF YOU HA VE ANY QUESTIONS THAT YOU THINK IMPORTANT TO YOUR DECISION AND CONSENT.

 

I understand and agree to mental health services that Sound Wellness Telepsychiatry is qualified to provide within:

1. The scope of the provider's license, certification, and training; or

2. The scope of the license, certification, and training of those mental health providers directly supervising the services I receive.

{Sound Wellness Telepsychiatry} Client Handbook Receipt

 

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  I have had the Client's Rights and Grievance Procedure explained to me.  A copy of these rights and procedures was printed out as my copy.

  I have been provided a copy of the Notice of Privacy Practices and have been notified of how my health information may be used and disclosed by Sound Wellness Telepsychiatry and how I may access and control this information.

By signing below, I also consent to use and/or disclosure my health information to treat me and arrange for my mental health care, to seek and receive payment for services given me, and for the business operations of Sound Wellness Telepsychiatry and its staff.

 

 

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For office use only: If the client does not sign this acknowledgment and consent form, record here the good faith efforts made to obtain this acknowledgment and consent or reason for lack of signature.