Notice of Privacy Practices Empathy and Empowerment, LLC

I, Rachel Cook, LMHC, am committed to providing service to you (the client) without regard to race, sex, ethnicity, age, religion, handicapping condition or sexual orientation.

As a client of mine:

·         You have the right to be treated in a respectful and confidential manner that maintains your individual dignity.

·         You have the right to nondiscriminatory services, to be provided services without regard to race, sex, ethnicity, age, sexual orientation, religion, AIDS/HIV status or handicapping condition.

·         You have the right to be involved and participate in the formulation and periodic review of your individualized service plan with your therapist. You have the right to ask questions, at any time, about what we do during therapy, and to receive answers that satisfy you.

·         You have the right to decide not to enter therapy with me. If you wish, I will provide you with the names of other good therapists.

·         You have the right to express dissatisfaction with therapy and/or end therapy at any time. You may also at anytime withdraw your consent for any specific activity used in the therapy sessions.

·         You have the right to have your records and information revealed to me kept confidential. I, Rachel Cook, LMHC, Have the obligation to obtain written consent from you prior to any exchange of confidential information. There are a few situations and exceptions to confidentiality which are listed below:

1.       If you present a danger to yourself or others, I am legally and ethically required by law to protect the safety of you and/ or the threatened person(s).

2.       If abuse (sexual or physical) or neglect of a child, elderly individual, or disabled person is revealed, known or suspected, I am required by law to report it to the child welfare department of the local state.

3.       If I receive a court order for client records, staff deposition or court testimony, I am required to comply.

In the event that group/family services are provided, it is acknowledged that I, Rachel Cook, LMHC, or any other co-therapists involved cannot be held responsible for a breech of confidentiality on the part of a group/family member.

Health Insurance Portability and Accountability Act Notice (HIPAA)

HIPAA is the United States Health Insurance Portability and Accountability Act of 1996. HIPAA seeks to establish standardized mechanisms for electronic data interchange (EDI), security and confidentiality of all healthcare-related data.

HIPAA protects your right to see copies of your medical treatment records (with some exceptions), have corrections made to your health information, receive a notice that tells you about how your health information is used and shared, and decide whether to give your permission about how your information can be used or shared in certain ways. You can also get a report on when your information was shared and for what purpose, provide contact information other than your home (within reason), and ask that your information not be shared, and file complaints with your treatment provider, insurer and/or the U.S. government. By signing this form, you are acknowledging that you have been informed of the existence of HIPAA and its intention to provide you with protections for your health and privacy records and have received a copy of the Notice of Privacy Practices used by Rachel Cook, LMHC. HIPAA rules and regulations are vast and numerous, and this document does not include the full list of HIPAA rules and regulations. You can learn more about HIPAA by going to http://www.hhs.gov/ocr/hipaa/. You are entitled to contact your provider, insurer and the U.S. Department of Health and Human Services for further information. This is not a conclusive list of your rights.