New Client Intake

Soundscape Studios Counseling
Effective date: March 15, 2020

 AS REQUIRED BY FEDERAL LEGISLATION, THIS NOTICE DESCRIBES HOW HEALTHCARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
– We are required by law to maintain the privacy and security of your protected health information.
– We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
– We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

How do we typically use or share your health information?
We typically use or share your health information in the following ways.

Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.

What we do not treat
– Autism
-ADHD
-Eating disorders
Chemical dependencies
Addiction
Chronic illness

Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

Help with public health and safety issues
We can share health information about you for certain situations such as:
– Preventing disease
– Reporting adverse reactions to medications
– Reporting suspected abuse, neglect, or domestic violence
– Preventing or reducing a serious threat to anyone’s health or safety 

Your Rights
You have the right to:
– Get a copy of your paper or electronic medical record (fees apply)
– Correct your paper or electronic medical record
– Request confidential communication
– Ask us to limit the information we share
– Get a list of those with whom we’ve shared your information
– Choose someone to act for you
– File a complaint if you believe your privacy rights have been violated

Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. 

File a complaint if you feel your rights are violated
– You can complain if you feel we have violated your rights by contacting us.
– You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/.