The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable Protected Health Information (PHI) used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential.

• Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment (psychological services), payment (billing managed care and insurance, hiring bill collectors, utilization reviews, audits) , and health care operations (business aspects, quality assessment)
• In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment options or other health-related services.
• We will use and disclose your PHI when we are required to do so by federal, state or local law. We may disclose your PHI to public health authorities that are authorized by law to collect information; to a health oversight agency for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding; response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
• We may release your protected health information to a medical examiner or coroner to identify a deceased individual or to identify cause of death. We may use and disclose your PHI to prevent a serious threat to your health of you or someone else.
• Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization any time.
• We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to it.

Complaint Resolution Procedure

If you have a complaint with a PCS staff member, pleases follow these procedures:

1. Bring the grievance to the attention of your therapist or evaluator in an attempt to resolve the grievance.
2. If the grievance remains unresolved, please bring it to the attention of the supervisor, Dr. Hartmann (craigrd38@yahoo.com). He will contact you to resolve the problem.

Supervision

These services are supervised by psychologist C.R. Hartmann, Ph.D. The supervisor reviews written information about those who receive evaluations and therapy. The supervisor has regular meetings with the mental health professional about your situation and progress.

My signature below indicates I understand the privacy policy, supervision arrangement and complaint procedure. It also gives Professional Consultation Services permission to provide me or my minor child psychological services with a mental health professional.