due upon service

INSPIRED THERAPY HIPPA I.A.I.
Tegan Sorvino Quille LCSW
51 JFK Parkway 1st Floor West
Short Hills, NJ 07078


This notice applies to individuals, or legal guardians or parents of minor children receiving services from Inspired Therapy, Tegan Sorvino Quille LCSW.

Protected health information excludes individually identifiable health information in Education Records covered by the Family Educational Rights and Privacy Act as amended 20 U.S.C. 1232G.

This notice describes how medical information about you may be used and disclosed and how to get access to this information.

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.

Our Responsibilities:
Maintain the privacy of your health information
Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
Abide by the terms of this notice
Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
Notify you if we are unable to agree to a requested restriction

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain should our privacy practices change we will provide you with a revised notice.

General Privacy Rule

We will not use or disclose your health information without your written authorization except as described in this notice.

Revoking your authorization: If you provide us with a written authorization to release your health information you may revoke that authorization at any time. A revocation must be in writing. A written revocation will not revoke your prior authorization if we have already released information pursuant to your prior authorization or if your insurance coverage requires your written authorization.






HIPPA I.A.I.

Separate authorization for psychotherapy notes:
We will not release any psychotherapy notes about you without a separate written authorization from you. You may revoke your specific written authorization at any time. A revocation must be in writing. A written revocation will not revoke your prior authorization if we have already released information pursuant to your prior authorization or if your insurance coverage requires your written authorization

How we may use or disclose your health information without your written authorization

Treatment
We may use your health information for your treatment. For example information obtained will be recorded in your record and maybe used to determine your diagnosis or the course of treatment that should work best for you. A doctor or other healthcare professional may share your information with other healthcare professionals who are either part of or outside of Inspired Therapy to determine how to diagnose or treat

Payment
We may use your health information for payment. For example, a bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you as well as your diagnosis procedures and supplies used.

Health care operations
We may use your health information for regular health operations. For example, staff may use information in your health record to assess the care and outcomes in your case and others like it.

Business associates
There are some services provided in our organization through contact with business associates. Examples include; our accountants, consultants and attorneys. When these services are contracted we may disclose your health information to our business associates so that they can perform the job we've asked them to do. To protect your health information however we require that the business associates appropriately safeguard your information.

Family and friends involved in your care
If you do not object we may share your health information with a family member a relative or close personal friend who is involved in your care or payment related to your care. We may also notify a family member, personal representative or another person responsible for your care about your location and general condition or about the unfortunate event of your death. In some cases we may need to share your information with a disaster relief organization that will help us to notify those persons.




HIPPA I.A.I.
Contacts .
We may contact you to provide appointment reminders for information about treatment alternatives or other health related benefits and services that may be of interest to you.

Workers compensation
We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public health
As required by law we may disclose your health information to public health or legal authorities charged with preventing or controlling disease injury or disability.

Correctional institution
Should you be an inmate of a correctional institution we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law enforcement
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Abuse neglect or domestic violence
We may disclose your health information to the extent provided by law to an authority, social service agency or protective services agency. If we reasonably believe that you have been a victim of abuse neglect or domestic violence we will notify you of this disclosure promptly unless it would place you at risk of serious harm.

Health oversight activities
We may disclose your health information to a health oversight agency for activities authorized by law such as audits, civil administrative or criminal investigations, inspections licensure or disciplinary actions or other activities necessary for oversight of the health care system government benefit programs government regulated programs or compliance with civil rights laws.

Judicial and administrative proceedings
We may disclose your health information in response to an order of a court or administrative tribunal or in response to a valid subpoena. If we receive satisfactory assurances from the party seeking the information that the party has made an attempt to notify you or to secure a protective order for your information.

National Scurity and intelligence activities
We may disclose your health information to authorized federal officials for national security activities.


HIPPA I.A.I.
Your Health Information Rights

Although your health record is the physical property of Inspired Therapy, Tegan Sorvino Quille LCSW the information in your health record belongs to you. You have the following rights.

You may request that we not use or disclose your health information for a particular reason related to treatment, payment, the centers general healthcare operations and or to a particular family member, other relative or close personal friend. We ask that such requests be made in writing. Although we will consider your request please be aware that we are under no obligation to accept it or to abide by it.

You have the right to receive confidential communications of your health information. If you are dissatisfied with the manner in which or location where you are receiving communications from us that are related to your health information you may request that we provide you with such information by alternative means or at alternative locations. Such request must be made in writing, We will accommodate all reasonable requests.

You may request to inspect and or obtain copies of health information about you which will be provided to you within 45 days. Such requests must be made in writing. If you request to receive a copy, you may be charged a reasonable fee.

If you believe that any health information in your record is incorrect or if you believe that important information is missing you may request that we correct the existing information or add the missing information. You must provide a reason to support your request, such requests must be made in writing.

You may request that we provide you with a written accounting of all disclosures made by us of your health information for up to a six year period of time; however, disclosures made prior to April 14, 2003 do not have to be accounted for by law. We ask that such requests be made in writing. Please note that an accounting will not include the following types disclosures; disclosures made for treatment, payment or healthcare operations; disclosures authorized by you or your legal representative; disclosures to correctional institutions or law enforcement officials or for national security purposes; disclosures made from the directory; and disclosures that are incidental to permissible uses and disclosures of your health information
(for example when information is overheard by another patient passing by). There is no charge for their first request for an accounting made in any 12 month period but there may be a reasonable charge for additional requests in the same 12 month period.

You have the right to obtain a paper copy of our notice of privacy practices upon request.

You may revoke any authorization to use or disclose health information, except to the extent that action has already been taken. Such request must be made in writing.

INSPIRED THERAPY
Tegan Sorvino Quille LCSW
51 JFK Parkway 1st Floor West
Short Hills, NJ 07078

Information and Client Consent
Please read and sign stating you have fully read and understand the information below.

Client/therapist Relationship and Services
Effective psychotherapy is founded on mutual understanding and good rapport between client and therapist, it is my intent to convey the policies and procedures used in this practice. I would be pleased to discuss any questions or concerns you may have.

Risks and Benefits
Counseling and psychotherapy are beneficial but as with any treatment there are inherent risks. During counseling you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress and specific problem-solving. These benefits cannot be guaranteed of course. It is my desire however to work with you to attain your personal goals for counseling coaching and or psychotherapy.

Payment/Insurance Filing
Payment of fees is expected at the time of appointment. There is a 48 hour cancellation policy, please cancel prior to the time to avoid being charged for the appointment. As an out of network provider, invoices need to be submitted to your insurance company. Invoices for insurance submission will be on the client portal, all necessary information for your insurance company will be listed on the invoice.

Emergencies
If you are experiencing a life threatening emergency call 911 or have someone take you to the nearest emergency room for help.

Confidentiality
Discussions between a therapist and client are confidential. No information will be released without the client's written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: Child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; HIV/AIDS infection and possible transmission; criminal prosecutions; child custody cases; suits in which the mental health of a party is in issue; situations where the therapist has a duty to disclose, or where in the therapist's judgment, it is necessary to warn or disclose; fee disputes between the therapist and the client; a negligence suit brought by the client against a therapist or the filing of a complaint with the licensing or certifying board.

Consent to treatment
By signing this client information and consent form as the client or guardian of said client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in the information and client consent form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receive mental health assessment, treatment and services for me (or my child if said child is the client), and I understand that I may stop such treatment or services at any time.

Duty to warn/Duty to protect
If my therapist believes that I (or my child if child is the client) am in any physical or emotional danger to myself or another human being, I hereby specifically gives consent to my therapist to contact any person who is in a position to prevent harm to me or another, including, but not limited to, the person in danger. I also give consent to my therapist to contact the following person (s) in addition to any medical or law enforcement personnel deemed appropriate.

Emergency Contacts Names and Telephone Numbers