ADDICTION RECOVERY COUNSELING SERVICES, LLC

120 E 5TH AVENUE AUGUSTA, KS 67010

P-(316) 351-7138

F-(316) 831-1272

PATIENT CONFIDENTIALY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL AND DRUG AND ALCOHOL RELATED INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Information regarding your health care, including payment for healthcare, is protected by two federal laws: the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. 1320d et seq., 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. 290dd-2, 42 C.F.R. Part 2.

Addiction Recovery Counseling Services must obtain your written consent before it can disclose information about you for payment purpose. For example, Addiction Recovery Counseling Services must obtain your written consent before it can disclose information to your health insure in order to be paid for services.

Addiction Recovery Counseling Services is also required to obtain your written consent before it can sell information about you or disclose information about you for marketing purposes, and Addiction Recovery Counseling Services must obtain your written consent before disclosing any of your psychotherapy records.

Federal Law permits Addiction Recovery Counseling Services to disclose information without your written permission:

Pursuant to an agreement with a qualified service organization/ business associate;
For research, audit or evaluations;
To report a crime committed on Addiction Recovery Counseling Services premises or against a Addiction Recovery Counseling Services personnel;
To medical personnel in a medical emergency;
To appropriate authorizes to report suspected child abuse or neglect;
As allowed by a court order.

Addiction Recovery Counseling Services can disclose information without your consent to obtain legal or financial services, or to another medical facility to providence health care to you, as long as there is a qualified services organization/ business associate agreement in place. Before Addiction Recovery Counseling Services can use or disclose any information about your health in a manner which is not described above, it must first obtain your specific writer consent allowing it to make the disclosure. Any such writer consent may be revoked orally or in writing. A violation of the Confidentiality Law by a program is a crime. Suspected violations of the confidentiality Law may be reported to the United States Attorney in the district where the violation occurs.

[ I hereby acknowledge that I received a copy of this notice. ]

[ I have declined a copy of this form ]

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