Early Life Child Psychology-Utah
10757 S River Front Parkway Suite 275
South Jordan, Utah 84095
Phone: 385-900-4020
Early Life Child Psychology-California
27441 Tourney Rd. Suite 260
Valencia, CA 91355
Phone: 661-312-2875
HIPAA PRIVAVY NOTICE FORM
PROFESSIONAL RECORDS AND CONFIDENTIALITY
This notice describes how medical information about you may be used and disclosed, and how
you can get access to this information. Please read it carefully.
How The Information In Your Record Is Utilized:
You should be aware that, pursuant of HIPAA, Early Life Psychology (ELP) keep Protected
Health Information (PHI) about you in two sets of professional records. One set constitutes your
Clinical Record. It includes information about your reasons for seeking therapy, a description of
the way in which your problem impacts on your life, your diagnosis, the goals that we set for
treatment, your progress towards those goals, your medical and social history, your treatment
history, any past treatment records that your therapist receives from other therapists, reports of
any professional consultations, your billing records, and any reports that have been sent to
anyone, including reports to your insurance carrier. Except in unusual circumstance that involve
danger to yourself and/or others or where information has been supplied to your therapist
confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you
request in writing. Because these are professional records, they can be misinterpreted and/or
upsetting to untrained readers. For this reason, ELP is allowed to charge a copying fee of $1.00
per page (and for certain other expenses). If your therapist refuses your request for access to your
Clinical Record, you have a right of review (except for information supplied to your therapist
confidentially by others), which your therapist will discuss with you upon request.
In addition, your therapist will also keep a set of Psychotherapy Notes. These notes are for your
therapist’s use and are designed to assist your therapist in providing you with the best treatment.
While the contents of Psychotherapy Notes vary from client to client, they can include the
contents of our conversations, an analysis of those conversations, and how they impact on your
therapy. They also contain particularly sensitive information that you may reveal to your
therapist that is not require to be included in your clinical record (and information that is
revealed to your therapist by others where he/she has promised confidentiality). These
Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes
are not available to you and cannot be sent to anyone else, including insurance companies
without your written, signed Authorization. Insurance companies cannot require your
authorization as a condition of coverage nor penalize you in any way for your refusal to provide
it.
ELP’s policies regarding your privacy are strictly followed in our practice. The laws of the State
of Utah and the standards of my profession require that I keep treatment records. The
information in your medical record is utilized in a number of ways. Your therapist will use it to
plan your treatmentand keep a record of the significant issues that are addressed in treatment.
Your therapist will also use the information to coordinate your treatment with other professionals
or to provide information to significant others or family members; information is only provided
to those that you have given permission in writing to communicate with regarding your
treatment. Utah law requires ELP to keep records for not less than 10 ten years. After 10 years,
the record will be destroyed.
Your insurance company may also require information in your medical record or health plan so
that the treatment you receive from me can be paid for by the insurance company or health plan.
For example, ELP may need to provide information about a service you received, or ELP may be
require to provide information prior to treatment so that your plan will cover the treatment. In
these cases, only information required for payment is provided to the insurance company or
health plan.
For patients under eighteen years of age, please be aware that the law provides parents the right
to examine treatment records. It is the policy of ELP to request an agreement from parents that
they agree to give up access to minor patient’s records. If they agree, the therapist will provide
them only with general information about the treatment, unless the therapist feels there is a high
risk that the minor patient is facing serious jeopardy or harm. In that case, the therapist will
notify parents of hi/her concern. The therapist will also provide them with a summary of your
treatment when it is complete. Before giving parents any information, the therapist will discuss
the matter with the minor patient, if possible, and do his/her best to handle any objections the
minor patient may have with what the therapist is prepared to discuss.
In general, federal and state laws protect the privacy of all communications between a patient
and a psychologist, and I can only release information about our work to others only with your
written permission. However, there are exceptions to confidentiality:
Exceptions To Your Confidentiality:
The law protects the privacy of all communications between a patient and a therapist. In most
situations, your therapist can only release information about your treatment to others if you sign
a written Authorization form that meets certain legal requirements imposed by HIPAA. There are
other situations that require only that you provide written, advance consent. By signing this
document, you are providing consent for those activities as follows:

Your therapist may occasionally find it helpful to consult with other health and mental
health professionals about a case. During a consultation, your therapist will make every
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effort to avoid revealing the identity of a patient. The other professionals are also legally
bound to keep the information confidential. If you do not object, your therapist will not
tell you about these consultations unless your therapist feels it is important for your work
together. Your therapist will note all consultations in your clinical Record (PHI).
You should be aware that this practice employs both clinical and administrative staff. In
most cases, your therapist may need to share information with these individuals for both
clinical and administrative purposes, such as scheduling, billing, and quality assurance.
All of the mental health professionals are bound by rules of confidentiality. All staff
members have been given training and protecting your privacy and have agreed not to
release any information outside of this practice without the permission of a clinical staff
member.
This practice utilizes electronic billing software and a collection agency. As required by
HIPAA, this practice has a formal business contract in which they promise to maintain
confidentiality of this data except as specifically allowed in the contract or otherwise
required by law.
There are some situations where your therapist is permitted or required to disclose information
without either your consent or authorization:
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If you are involved in a court proceeding, the patient-therapist privilege provides a degree
of protection. However, if a judge issues an order for the records, your therapist is
required to release those records. Otherwise, your records will not be released without a
signed authorization by you or your legal representative. If you are involved in or
contemplating litigation, you should consult with your attorney to determine whether a
court would be likely to order your therapist to disclose information. If a government
agency is requesting the information for health oversight activities, your therapist is
required to provide it for them.
If a patient files a complaint or lawsuit against a therapist, the therapist may disclose
relevant information regarding a patient in order to defend him/herself.
If a patient files a worker’s compensation claim, your therapist must, upon appropriate
request provide a copy of the patient’s record to the appropriate parties, the patient’s
employer, the workers’ compensation insurance carrier or the Labor Commission.
There are some situations in which your therapist is legally obligated to take action. Whenever
your therapist judges that it is necessary to protect the patient or others from harm, your therapist
may have to reveal some information about a patient’s treatment. These situations are unusual in
our practice. These include:
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If your therapist has reason to believe that a child has been or is likely to be subjected to
incest, molestation, sexual exploitation, sexual abuse, physical abuse, witnessing
domestic violence, or neglect, the law requires that your therapist notify the Division of
Child and Family Services (DCFS) or an appropriate law enforcement agency. Once such
a report is filed, your therapist may be required to provide additional information.
If your therapist has reason to believe that any vulnerable adult has been the subject of
abuse, neglect, abandonment, or exploitation, your therapist is required to immediately
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notify Adult Protective Services ( APS) intake. Once such a report is filed, your therapist
may be required to provide additional information.
If a patient communicates an actual threat of physical violence against an identifiable
victim, your therapist is required to take protective actions. These actions may include
notifying the potential victim and contacting the appropriate law enforcement agency,
and/or seeking hospitalization for the patient. In choose to work with this practice, you
also agree to and understand that if there is an identifiable class of victims, your therapist
will notify law enforcement of the danger.
If a patient threatens to harm him/herself, your therapist may be obligated to seek
hospitalization for him/her, and/or to contact family members, law enforcement, or others
who can help provide protection.
If communicable disease is reported to me, your therapist is required to report that
disease to the Utah State Department of Health. Reportable communicable diseases
include, but not limited to: AIDS, Hepatitis, Sexually Transmitted Diseases, and
Smallpox.
YOUR RIGHTS REGARDING MEDICAL INFORMATION IN YOUR RECORD
Right to Inspect and Copy:
You are entitled to receive a copy of your medical record unless your therapist believes that
received that information would be emotionally damaging. Because these are professional
records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your
records or receive a copy of your records, ELP requires written notice to that effect, and your
therapist would expect to discuss your request with you in person. If your therapist denies you
access to your records, you can request to speak with an independent colleague of ELP of about
your request. Your request for independent review of your request should also be made in
writing. If you are provided with a copy of your medical record information, your therapist may
charge a fee for any costs associated with that request.
Right to Amend:
If you believe that the information your therapist has about you is incorrect or incomplete, you
may ask him/her to amend that information. It is ELP practice to accept this sort of request in
writing, and that any information you may wish to add to your record also be provided to your
therapist in written form. If the information is accurate, however, or if it has been provided by a
third party (previous therapist, primary care physician, etc.), it may remain unchanged, and the
request may be denied. In this case you will receive an explanation in writing with a full
description of the rationale. You also have the right to make an addition to your record if you
think it is incomplete.
Right to an Accounting of Disclosures:
You have the right to request an “Accounting of Disclosures.” This is a list of the disclosures
ELP has made of medical record information. That information is listed on the Authorization to
Release Information, and will be provided to you at your written request.
Right to Request Restrictions:
You have the right to privacy, and to request a restriction or limitation on the health information
we use or disclose about you for treatment, payment or health care operations. As noted above,
your therapist will not release your confidential information without your written permission.
Any restrictions to your Authorization to Release Information should be specified on the
Authorization.
Right to Request Confidential Communications:
You have the right to request that your therapist communicate with you only in certain ways. For
example, you can ask that ELP not leave a telephone message for you, or that ELP only contact
you at work or by mail.
Complaints Regarding Privacy Rights:
If you believe your privacy rights have been violated, you may file a written complaint with your
therapist, or with an independent colleague of ELP, or with the Secretary of the Department of
Health and Human Services in Washington, D.C. you will not be penalized for filing a
complaint.
You have the right to a paper copy of this document, and you will be offered one when you sign
the original for your medical record. ELP reserves the right to change any policies as outlined
herein. If they change, you will be informed of that change and will be provided with a copy of
the current document if desired.
By signing this Privacy and HIPAA notice, I am indicating that I understand the
information provided to me. I also am acknowledging that I have had the opportunity to
ask question, and that any questions have been answered to my satisfaction.
____________________________________
Print Guardian Name
____________________________________
Signature of Guardian
________________________
Date
____________________________________
Witness
________________________
Date
Complaints Regarding Privacy Rights:
If you believe your privacy rights have been violated, you may file a written complaint with your
therapist, or with an independent colleague of ELP, or with the Secretary of the Department of
Health and Human Services in Washington, D.C. you will not be penalized for filing a
complaint.
You have the right to a paper copy of this document, and you will be offered one when you sign
the original for your medical record. ELP reserves the right to change any policies as outlined
herein. If they change, you will be informed of that change and will be provided with a copy of
the current document if desired.
By signing this Privacy and HIPAA notice, I am indicating that I understand the
information provided to me. I also am acknowledging that I have had the opportunity to
ask question, and that any questions have been answered to my satisfaction.
____________________________________
Print Guardian Name
____________________________________
Signature of Guardian
________________________
Date
____________________________________
Witness
________________________
Date