John J. Blum, MS, MSEd, LCADC, LPC Confidentiality
If you choose to engage in counseling or psychotherapy services with me, please be advised that
You do so voluntarily.
are aware that the pra ctice of such services is not an exact science.
ctice of such services is not an exact science.
No guarantees have been made or implied as to the outcome of such treatments or services.
your participation in such services entitles you to limitations as described in
Title 42 of the Code of Federal Regulations governing the confidentiality of
mental health and alcohol/drug abuse information (42 CFR - Part 2), as well as
other federal and state laws further regulating protected health information
(PHI) in order to facilitate treatment, payment, or healthcare operations (TPO).
Information in your patient record will only be released to external
parties or agencies through a separate, written authorization signed by you,
except under the following circumstances:
In response to an immediate or imminent medical emergency
In response to a clear and present danger to yourself or someone else
In response to suspected child or elder abuse/neglect
In response to an order of the court
In order to facilitate coordination and continuity of care planning with other healthcare professionals actively engaged in your treatment, including persons at other facilities where you are being referred (medical, correctional, etc.) who require such information for admission and ongoing care
In response to third party payers, to the extent that facilitates payment and does not compromise clinical confidentiality
In response to external reviewing agencies when necessary to obtain or renew certifications or licenses as a provider of psychotherapy and related services
made available under this section shall be limited to that information relevant
and necessary to the purpose for which the information is being sought.
Otherwise, an Authorization for the Release of Confidential Information
Federal rules based on 42 CFR - Part 2 restrict the use of client
information to criminally investigate or prosecute any alcohol or drug abuse
you have any questions or concerns regarding confidentiality of information,
please contact me by e-mail.
Copyrightę 2004-2011 Blum & Associates, LLC