Jayna Klatzker, LICSW
1 Richmond Square, Providence, RI 02903
HIPAA NOTIFICATION
CONFIDENTIALITY POLICY
The law protects the privacy of all communications between a patient and a psychotherapist. In most
situations, we can only release information about your treatment to others if you sign a written
authorization for specific information to be released to specific individuals or institutions. There are other
situations that require only that you provide written, advance consent. Your signature on this Agreement
provides consent for those activities, as follows:
● Your therapist may occasionally find it helpful to consult other health and mental health professionals
about a case. During a consultation, your therapist will not reveal the identity of their patient. The other
professionals are also legally bound to keep the information confidential.
● There are some situations where we are permitted or required to disclose information without either
your consent or Authorization:
● If you are involved in a court proceeding and a request is made for information concerning our
professional services, such information is protected by the psychotherapist-patient privilege law. We
cannot provide any information without your (or your legal representative’s) written authorization, or a
court order, or a subpoena of which you have been officially notified and failed to inform us that you are
opposing the subpoena. If you are involved in or contemplating litigation, you should consult with your
attorney to determine whether a court would be likely to order us to disclose information.
● If you threaten to harm yourself, your therapist may be obligated to seek hospitalization for you or to
contact family members or others who can help provide protection.
If a government agency is requesting the information for health oversight activities, we may be required to
provide it for them.
● If a patient files a complaint or lawsuit against a therapist or the practice, we may disclose relevant
information regarding that patient in order to defend ourselves.
● If a patient files a worker’s compensation claim, information that is directly related to that claim must,
upon appropriate request, be provided to the Workers’ Compensation Commission.
There are some situations in which your therapist is legally obligated to take actions to attempt to protect
others from harm. They may have to reveal some information about a patient’s treatment. These
situations are unusual in our practice.
● If they have reason to know or suspect that a child has been abused or neglected, or has been a
victim of sexual abuse by another child, the law requires that they file a report with the Department for
Children, Youth and Families. Once such a report is filed, they may be required to provide additional
information.
If your therapist believes that a patient presents a risk to a person or his/her family, your therapist may be
required to take protective actions including warning the potential victim(s), contacting the police, or
seeking hospitalization of the patient.
If such a situation arises, your therapist will make every effort to fully discuss it with you before taking any
action and they will limit disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about
potential problems, it is important that you discuss any questions or concerns that you may have now or
in the future. The laws governing confidentiality can be quite complex. In situations where specific advice
is required, formal legal advice may be needed.
OFFER TO RECEIVE THE NOTICE OF OUR PRIVACY POLICIES
The Rhode Island Notice Form describes our policies and practices to protect the privacy of your health
information, as mandated by a federal law called the Health Insurance Portability and Accountability Act
(HIPAA). Signing the Services Agreement indicates that you have been made aware that a copy of this
Form is available in the waiting room, is posted on our web site (Jaynaklatzker.com), and will be given to
you at any point if you request it.
PROFESSIONAL RECORDS
The laws and standards of our professions require that we keep Protected Health Information about you
in your Clinical Record. You may examine and/or receive a copy of your Clinical Record, if you request it
in writing. Because these are professional records, they can be misinterpreted and/or upsetting to
untrained readers. For this reason, we recommend that you initially review them in your therapist’s
presence, or have them forwarded to another mental health professional so you can discuss the
contents. In most circumstances, we charge a record preparation fee of $75.
PATIENT RIGHTS
The Health Insurance Portability and Accountability Act (HIPAA) provides you with rights with regard to
your Clinical Record and disclosures of protected health information. These rights include requesting that
we amend your record; requesting restrictions on what information from your Clinical Record is disclosed
to others; requesting an accounting of most disclosures of protected health information that you have
neither consented to nor authorized; determining the location to which protected information disclosures
are sent; having any complaints you make about our policies and procedures recorded in your records;
and the right to a paper copy of this Agreement, and the Notice of Privacy Policies form. Your therapist
can discuss any of these rights with you.
I acknowledge receipt of this statement.
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Name
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Signature
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Date
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