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Privacy and Disclosure Authorization Policy:
For Storage and Disclosure of Confidential Information and Records

  1. This Notice describes how your health information, including therapy records, may and may not be used and disclosed to others, and how you may gain access to this health information. Please review the information in this notice carefully.
  2. The Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides strict guidelines about the maintenance, use, storage and disclosure of client medical information called Protected Health Information (PHI). HIPAA also requires that those who receive health services be given written statements of the privacy policies of the health providers. In addition to HIPAA guidelines, there are many other federal, state, and professional guidelines and ethical standards that inform our policies and practices at Shoreside Therapies, LLC. While we are required to keep records of services provided, we are also required to safeguard this information. Shoreside Therapies, LLC will personnel make every effort to safeguard your privacy and your rights.
  3. You as a health services consumer have a right to know how information about you and about services you receive may be used. You also have rights to ask for limits on the disclosures made on your behalf, and to have appropriate access to you records for review and release.
  4. The Policies and practices of Shoreside Therapies, LLC regarding PHI privacy and disclosure are contained in the notice. The purposes for the maintaining and disclosing of client records relates to providing services, as requested by our clients, and generally are involved in treatment, payment, and other health operations, such as those required by government agencies or in emergency situations.
  5. Based on legal regulations and ethical guidelines, Shoreside Therapies, LLC will only disclose information about you to persons or organizations outside of our clinic in a limited number of situations:
    a. With your written and specific permission (consent).
    b. If required to do so by certain specific court orders, subpoenas, or Workers’ compensation inquiries
    c. In cases where laws require reporting for protection, such as significant danger to self or others, child or elder abuse
    or neglect
    d. When confidential audits are lawfully conducted by governmental or insurance oversight agencies (such as for
    clinic licensing.
    e. When an emergency required immediate communication with appropriate persons in order to secure appropriate help or treatment: in these situations, the minimum disclosure necessary to secure services will be provided.
    f. In order to bill for services provided by Shoreside Therapies. Payers are typically insurance companies or other responsible parties. Billing services and insurance companies are also bound by HIPAA and other governmental agencies.
    g. When a client in AODA treatment is transferred or completes treatment, follow-up contact is required by statute.
    h. Note: when the client is a minor, privacy rights belong to the parents, except in certain situations. Please discuss age-related rights with your therapist.
  6. Based on legal regulations and ethical guidelines, Shoreside Therapies will use or disclose your PHI within clinic:
    a. To provide services to you, including: Consultation and coordination of services among personnel and professional consultants (as appropriate), in order to aid in diagnosis, assessment and treatment planning, and in facilitation of ongoing treatment, with professional supervision as required by law.
    b. To maintain business records, for example, support staff may document payment receipts.
    c. To contact you when appropriate, and with as little disclosure as feasible, for example, about appointments.
    d. To maintain treatment records, as required legally and ethically. We maintain client records in file folders, kept in locked file cabinets, and are destroyed by shredding after they have been held as required by law (and not less than seven years after client discharge). Shoreside Therapies, LLC also maintains records on computer, respecting legal and ethical privacy guidelines.
    e. To share and discuss with you your PHI as contained in clinic records, with a prior written request; also, you may update or correct (add to) your PHI as needed. State law does provide some restrictions on these rights (when judged to be in your best interest). In addition, you may request a listing of non-routine disclosures made of your PHI records. You may also choose how we communicate with you, as via an alternative address or phone number.
    f. Examples of other situations that might involve disclosure: Consultation regarding emergency planning, defense of lawsuits, or processing of grievances, or you bringing a friend with you during therapy sessions.
  7. Psychotherapy notes, kept by the therapist to support the treatment process, are not considered part of the formal clinic record, and will not generally be disclosed within or outside of the clinic. Only in very special situations will the authorization (permission above and beyond general consent) for release of these more sensitive records be considered. For example, insurance companies are not permitted to request access to psychotherapy notes for billing purposes.
  8. Consent: Your signature below indicates that you are aware of the collection and storage of treatment, payment and other health care information, and that you consent to its use in the course of service provision, billing and collection procedures, and within Shoreside Therapies, LLC, as discussed above. This form has no expiration date, unless amended or revoked. You may restrict this consent with written notice at any time, except to the extent that it has already been acted upon. You may revoke the released information and its use, as indicated on the appropriate form, or restrict its use within Shoreside Therapies, LLC, but doing so may legally or ethically compromise our ability to provide you with therapy services. We may therefore determine that we are unable to provide those services in good faith
  9. There is a separate form for consent to release/exchange information with your insurance company or other third party payer.
  10. Other relevant information: Fees for Copying Records: A uniform and reasonable fee may be charged for copying records. That fee may be reduced or waived in accordance with Shoreside Therapies policy. Shoreside Therapies, LLC will ordinarily have 2 weeks to respond to a request to copy records. Transportation of Records: Whenever records must be transported out of the office, great care will be taken to protect client privacy. Electronic Transmissions: E-mail and Internet communications may be used within Shoreside Therapies, LLC. In those rare instances, Shoreside Therapies, LLC staff will take care to limit identifying information within the messages, and to make sure the recipient is authorized to receive the information. Future Changes: Shoreside Therapies, LLC will revise and update this information and form as needed, and in compliance with the law. Complaints: Shoreside Therapies, LLC has a Grievance Policy posted in the office: clients may ask any Shoreside Therapies, LLC therapist for a copy of the policy. You may also contact any Shoreside Therapies, LLC therapist for further information about our privacy and disclosure policies, or about HIPAA questions. Privacy concerns may be addressed to the Secretary of the U.S. Department of Health and Human Services. Information and assistance may be found through the HHS Office for Civil Rights (website: www.hhs.gov/ocr/hipaa).