NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES/Registration
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Introduction
Water’s Edge Counseling and Healing Center., is committed to treating and using protected health information about you responsibly. This Notice of Health Information Privacy Practices describes the personal information I collect, and how and when I use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 5, 2003 and applies to all protected health information as defined by federal regulations

Understanding Your Health Record/Information
Each time you visit Water’s Edge Counseling and Healing Center, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• Basis for planning your care and treatment,
• Means of communication among the many health professionals who contribute to your care,
• Legal document describing the care you received,
• Means by which you or a third-party payer can verify that services billed were actually provided,
• A tool in educating health professionals
• A source of information for public health officials charged with improving the health of this state and the nation,
• A source of data for our planning and marketing,
• A tool with which I can assess and continually work to improve the services rendered and the outcomes achieved.

Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights
Although your health record is the physical property of Water’s Edge Counseling and Healing Center., the information belongs to you. You have the right to:

• Obtain a paper copy of this notice of information practices upon request,
• Inspect and copy your health record as provided for in 45 CFR 164.524,
• Amend your health record as provided in 45 CFR 164.528,
• Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528,
• Request communications of your health information by alternative means or at alternative locations,
• Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522, and
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Responsibilities of My Practice
Water’s Edge Counseling and Healing Center is required to:

• Maintain the privacy of your health information,
• Provide you with this notice as to my legal duties and privacy practices with respect to information I collect and maintain about you,
• Abide by the terms of this notice,
• Notify you if I am unable to agree to a requested restriction, and
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

I reserve the right to change my practices and to make the new provisions effective for all protected health information I maintain. Should my information practices change, I will give you in person, or mail a revised notice to the address you’ve supplied me.

I will not use or disclose your health information without your authorization, except as described in this notice. I will also discontinue using or disclosing your health information after I have received a written revocation of the authorization according to the procedures included in the authorization.

For More Information or to Report a Problem

If you have questions, would like additional information, or believe your privacy rights have been violated, you can contact the Office for Civil Rights. There will be no retaliation for filing a complaint. The address for the OCR is listed below:

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201

I have received the Health Information Privacy Practices notice and I have been provided an opportunity to review it.
Name________________________________________ Birth Date___________________

Signature______________________________________Date___________________