HIPAA Form

NOTICE OF PRIVACY AND CONFIDENTIALITY POLICIES

Clinicians are dedicated to preserving the confidentiality and privacy of our clients. Some state laws, however, specify certain circumstances when mental health professionals may be required to break confidentiality. Clinicians are required by the State of New Jersey to inform our clients of these limits on confidentiality:
1. If the client presents a clear and present danger to himself and refuses to accept appropriate treatment, the clinician may release relevant information to protect the client.
2. If the client communicates to the clinician an actual threat of physical violence against a clearly identified or reasonable identifiable victim(s), relevant information may be released to protect the potential victim(s).
3. If the client has a history of physical violence which is known to the clinician, and the clinician has a reasonable basis to believe that there is a clear and present danger of physical violence against a clearly identified or reasonably identifiable victim(s), relevant information may be released to protect the potential victim(s).
4. If there is a threat of imminent dangerous activity by the patient against himself or another person(s), the clinician may disclose client communications for the purpose of placing or retaining the client in a psychiatric hospital.
5. If the client introduces his mental condition as an element of claim or defense in a legal proceeding (except one involving child custody or adoption) the judge may order the clinician to disclose confidential client communications.
6. If, after the death of a client, any party acting on behalf of the decedent introduces evidence of the client’s mental condition as an element of claim or defense, the judge may order the clinician to disclose confidential client communications.
7. In any case of child custody or adoption, the judge may order the clinician to disclose confidential client communications if the judge determines that the clinician has evidence bearing significantly on the client’s ability to provide suitable care or custody and it is more important to the welfare of the child that the communication be disclosed than that the relationship between client and clinician be protected (in cases of adoption, or dispensing with consent to adoptions, the judge must determine that the patient has been informed that communications to the clinician would not be privileged.
8. If the client initiates legal action (i.e. malpractice, criminal or license revocation) against the clinician, the clinician may disclose confidential client communications if disclosure may be necessary or relevant to the clinician’s defense.
9. The clinician may provide diagnostic or treatment information to an insurance company or review board, non-profit hospital or medical service corporation or health maintenance organization for the purpose of administration or provision of benefits and expenses.
10. If the clinician, in her professional capacity, has reasonable cause to believe that a child under the age of eighteen years is suffering serious physical or emotional injury resulting from abuse inflicted upon the child (including sexual abuse), or from neglect (including malnutrition), or who is determined to be dependent upon an addictive drug at birth, the clinician is required to report information to the State of New Jersey Social Services.
11. If the clinician has reasonable cause to believe that an elderly person (over age 60) or a handicapped or disabled person over the age of 18 has died or is suffering abuse, the clinician may be obligated to report this information to the proper state agency.
12. Information acquired by a clinician in the course of her professional practice may be disclosed to another appropriate professional as part of a professional consultation.
13. If a judge compels the clinician to reveal confidential client information.
Apart from the above-listed exceptions, client information may only be shared upon express written consent of the client or parent/guardian.

I hereby acknowledge that I have read the Notice of Privacy and Confidentiality Policies for the practice of . I understand that if I have any questions regarding the above, I can speak with my clinician. A copy of these policies can be provided to you upon request.

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HIPAA Form

NOTICE OF PRIVACY AND CONFIDENTIALITY POLICIES

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