HIPAA AUTHORIZATION OF USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

I. Uses and Disclosures for Treatment ̈Payment ̈ and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and healthcare operations purposes with your consent.

II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures.

In those instances when I am asked for information for purposes outside of treatment, payment, and health care operations I will obtain an authorization before releasing your treatment notes. You may revoke all such authorizations (of PHI or treatment notes) at any time, provided each revocation is in writing. You may not revoke an authorization if:

a) I have relied on that authorization; or
b) The authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:

-Child Abuse: If you give me information that leads me to suspect child abuse, neglect, or death due to maltreatment, I must report such information to the county Department of Social Services.
- Adult and Domestic Abuse: If you give me information to suspect an adult is in need of protective services, I must report to the Department of Social Services.

I have read and I understand the Privacy Policy and the information regarding treatment.