Health Insurance Portability Accountability Act (HIPAA)
Client Rights & Therapist Duties


This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.  HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations. The Notice explains HIPAA and its application to your PHI in greater detail. 

The law requires that we obtain your signature acknowledging that we have provided you with this notice. If you have any questions, it is your right and obligation to ask so we can have further discussion prior to signing this document.  When you sign this document, it will also represent an agreement between us.  You may revoke this agreement in writing at any time.  That revocation will be binding unless we have taken action in reliance on it. 

Limits on Confidentiality The law protects the privacy of all communication between a patient and a therapist.  In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where we are permitted or required to disclose information without either your consent or authorization. If such a situation arises, we will limit the disclosure to what is necessary. Reasons we may have to release your information without authorization:

1. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the therapist-patient privilege law. We cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or if we receive a subpoena of which you have been properly notified and you have failed to inform us that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a

court would be likely to order us to disclose information.

2. If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, we may be required to provide it for them.

3. If a patient or their legal representative files a complaint or lawsuit against us, we may disclose relevant information regarding that patient in order to defend ourselves.

4. If a patient files a worker’s compensation claim, and we are providing necessary treatment related to that claim, we must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient’s employer, the insurance carrier or an authorized qualified rehabilitation provider.

5. We may disclose the minimum necessary health information to our business associates that perform functions on our on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm, and we may have to reveal some information about a patient’s treatment:

1. If we know, or have reasonable cause to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires that we file a report with Mississippi (MS) Child Protective Services. If we know, or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires that we file a report with MS Adult Protective Services. Once a report is filed, we may be required to provide additional information.

2. If we believe that there is a clear and immediate probability of physical harm to the patient, to other

individuals, or to society, we may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police. We may also disclose information in order to seek hospitalization of the patient.


Use and Disclosure of Protected Health Information

For TreatmentWe use and disclose your health information internally in the course of your treatment.  If we wish to provide information outside of our practice for your treatment by another health care provider, we will have you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.

For Payment – We may use and disclose your health information to obtain payment for services provided to you as delineated in the Consent for Billing.

For Operations – We may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. We may also use your information to tell you about services, educational activities, and programs that we feel might be of interest to you.


Client rights and therapist duties. Patient’s Rights:

Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category. 

Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service out-of-pocket in full, you can ask us not to share that information for the purpose of payment with your health insurer.  We will agree to such

unless a law requires us to share that information.

Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of your PHI. However, we are not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.

Right to AmendIf you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information.  You have to make this request in writing.  You must tell us the reasons you want to make these changes, and we will decide if it is reasonable. If we refuse to amend, we will notify you of the reason within 60 days. 

Right to Release Information with Written Consent With your written consent, any part of your record can be released to any person or agency you designate.  Your therapist can discuss with you whether or not releasing the information in question to that person or agency might be harmful to you.   

Right to a Copy of This NoticeIf you received this paperwork electronically a printed copy will be provided to you per your request or at any time.

Right to an Accounting You generally have the right to receive an accounting of disclosures of regarding you. Upon your request, we will discuss with you the details of the accounting process.

Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information. Before taking any action, we will make sure

that person has this authority and can act for you.

Right to Choose Services You have the right to decide not to receive services with us. If you wish, we will provide you with names of other qualified professionals. 

Right to Terminate You have the right to terminate therapeutic services with us at any time without any legal or financial obligations other than those already accrued.  We ask that you discuss your decision with your therapist in session before terminating or at least contact us to let us know you are terminating services.


Therapist’s Duties:

We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.  We reserve the right to change the privacy policies and practices described in this notice.  Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.  If we revise our policies and procedures, your therapist will provide you with a revised notice in office during your next session.



If you are concerned that we have violated your privacy rights, or you disagree with a decision made about access to your records, you may contact us, the MS Department of Health, or the Secretary of the U.S. Department of Health and Human Services.