HIPAA Summary and Notice of Privacy Practices

DO NOT fill out this form unless instructed by Dr. Fitzgerald. This form is only for current clients. If you are not a current client, your responses will be deleted.

The following is a required “notice of privacy practices” (NPP) in keeping with Federal HIPAA (Health Insurance Portability and Accountability Act, 1996) requirements. Please sign this form ONLY after we have scheduled an initial appointment.

If you wish to keep a copy of my Notice of Privacy Practices, simply print out this webpage.

Overview of privacy issues:

The laws regarding privacy of personal health information are covered by Federal as well as State regulations. Federal regulations require your approval this Notice of Privacy Practices as part of receiving health services. You also may have additional questions or concerns, including about situations not covered by this information, and you are encouraged to voice these. The health information in your records will be mainly used to provide treatment, to arrange payment for services, and for some other business activities that are called, by the law, “health care operations.” Before private information can be disclosed (sent, shared, or released) for any additional purposes, a separate authorization form is required to allow it. Your health information is private and will be kept that way, but there are some times when the law requires disclosure. For example:

  1. When there is a serious threat to your health or safety or the health or safety of another individual or the public. Information would then be shared with a person or organization that is able to help prevent or reduce the threat.
  2. When situations occur in which the therapist’s duties as a mandated reporter of known or suspected child abuse or neglect require notifying the Illinois Department of Children and Family Services.
  3. Some lawsuits and legal or court proceedings. (Subpoenas, without specific client consent, are generally not a valid basis to disclose information; and a judge’s order specifying the information to be released is generally needed)..
  4. If a law enforcement official requires that I do so.
  5. For Workers Compensation and similar benefit programs.
  6. There are some other situations, such as those governing certain safety-sensitive occupations, which happen more rarely. Privacy issues relating to those situations will be described separately as the need arises.
Your rights regarding your health information
  1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place for more privacy. For example, you could ask me to call you at home and not a work to schedule or cancel an appointment. I will try my best to do as you ask.
  2. You can request that I limit what is disclosed to any people who are involved in your treatment or the payment for treatment, such as family members or friends. If I agree to the request, I would attempt to keep that agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you.
  3. You have the right to look at your health information, such as billing records or health records, such as psychotherapy notes. You can even get a copy of these, provided that you reimburse for time and copy expenses involved.
  4. If you believe that any information in your records is incorrect or missing important information, you can ask to make some kinds of changes (termed “amending”) to your health information. You would have to make such a request in writing and send it to my office, and you would also need to write the reasons that you want to make the changes.
  5. You have the right to a copy of this notice (the NPP). If I make any changes to either form, I will make sure that they are readily available to you.
  6. You have the right to file a complaint if you believe that your privacy rights have been violated. You can file such a complaint with me personally and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint regarding privacy will not in itself change the health care that you receive at this office.

If you have any questions regarding this notice or the health information privacy policies at this office, please contact Paul Fitzgerald, Psy.D., LCPC, as the Privacy Officer for the purposes of the above issues. The effective date of this notice is December 1, 2009. I/We have read and accepted the privacy provisions stated above for counseling and psychotherapy services.

Acceptance of Privacy Policies

  • MM slash DD slash YYYY

CC BY-ND 4.0 Notice of Privacy Practices (for New Scheduled Clients) by Fitzgerald Counseling is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.