NOTICE FOR MEDICAL INFORMATION: Pages 1 – 5.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We 1 are required by law to protect the privacy of your health information. We are also required to provide you this notice, which explains how we may use information about you and when we can give out or “disclose” that information to others. You also have rights regarding your health information that are described in this notice. We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care. We will comply with the requirements of applicable privacy laws related to notifying you in the event of a breach of your health information.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, and if we maintain a website, we will post a copy of the revised notice on our website https://www.reachlink.com/privacy-policy. If we maintain a physical delivery site, we will also post a copy in at our office. The notice will also be available upon request. We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and

To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected.

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

For Payment. We may use or disclose health information to obtain payment for health care services. For example, we may disclose your health information to your health plan in order to obtain payment for the medical services we provide to you. We may ask you for advance payment.

For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care. For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.

For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services. We may also de-identify health information in accordance with applicable laws. After that information is de-identified, it is no longer subject to this notice and we may use it for any lawful purpose.

To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law.

For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances:

As Required by Law. We may disclose information when required to do so by law.

To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity. If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests. Special rules apply regarding when we may disclose health information to family members and others involved in a deceased individual’s care. We may disclose health information to any persons involved, prior to the death, in the care or payment for care of a deceased individual, unless we are aware that doing so would be inconsistent with a preference previously expressed by the deceased.

For Public Health Activities such as reporting or preventing disease outbreaks to a public health authority. We may also disclose your information to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA for purposes related to safety or quality issues, adverse events or to facilitate drug recalls.

For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.

For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.

For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.

For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.

To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster.

For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.

For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.

For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets federal privacy law requirements.

To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.

For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.

To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required, under contract with us and pursuant to federal law, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract and permitted by law.

Additional Restrictions on Use and Disclosure. 

Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. Such laws may protect the following types of information:

1. Alcohol and Substance Abuse

2. Biometric Information

3. Child or Adult Abuse or Neglect, including Sexual Assault

4. Communicable Diseases;

5. Genetic Information

6. HIV/AIDS

7. Mental Health

8. Minors Information

9. Prescriptions

10. Reproductive Health

11. Sexually Transmitted Diseases

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you. This includes, except for limited circumstances allowed by federal privacy law, not using or disclosing psychotherapy notes about you, selling your health information to others, or using or disclosing your health information for certain promotional communications that are prohibited marketing communications under federal law, without your written authorization. Once you give us authorization to release your health information, we cannot guarantee that the recipient to whom the information is provided will not disclose the information. You may take back or “revoke” your written authorization at any time in writing, except if we have already acted based on your authorization. To find out how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.”

What Are Your Rights

The following are your rights with respect to your health information:

You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction other than with respect to certain disclosures to health plans as further described in this notice.

You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you or a person on your behalf has paid us in full. We will agree to all requests meeting the above criteria and that are submitted in a timely manner.

You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address). We will accommodate reasonable requests. In certain circumstances, we will accept your verbal request to receive confidential communications; however, we may also require you confirm your request in writing. In addition, any request to modify or cancel a previous confidential communication request must be made in writing. Mail your request to the address listed below.

You have the right to see and obtain a copy of certain health information we maintain about you such as medical records and billing records. If we maintain a copy of your health information electronically, you will have the right to request that we send a copy of your health information in an electronic format to you. You can also request that we provide a copy of your information to a third party that you identify. In some cases, you may receive a summary of this health information. You must make a written request to inspect or obtain a copy your health information or have your information sent to a third party. Mail your request to the address listed below. In certain limited circumstances, we may deny your request to inspect and copy your health information. If we deny your request, you may have the right to have the denial reviewed. We may charge a reasonable fee for any copies.

You have the right to ask to amend certain health information we maintain about you such as medical records and billing records if you believe the information is wrong or incomplete. Your request must be in writing and provide the reasons for the requested amendment. Mail your request to the address listed below. If we deny your request, you may have a statement of your disagreement added to your health information.

You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) for treatment, payment, and health care operations purposes; (ii) to you or pursuant to your authorization; and (iii) to correctional institutions or law enforcement officials; and (iv) other disclosures for which federal law does not require us to provide an accounting.

You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. If we maintain a website, we will post a copy of the revised notice on our website. You may also obtain a copy of this notice on our website, https://www.reachlink.com/privacy-policy or by calling 1-833-732-2489.

Exercising Your Rights

Contacting your Provider. 

If you have any questions about this notice or want information about exercising any of your rights, please call 1-833-732-2489.

Submitting a Written Request. 

You can mail your written requests to exercise any of your rights, including modifying or cancelling a confidential communication, requesting copies of your records, or requesting amendments to your record, to us at the following address:

FLORIDA REACHLINK LLC

3651 FAU BLVD

STE 400

Boca Raton, FL 33431

Filing a Complaint. 

If you believe your privacy rights have been violated, you may file a complaint with us at the address listed above.

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

BY CHECKING THE BOX BELOW BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

1 This Medical Information Notice of Privacy Practices applies to REACHLINK TELEBEHAVIORAL HEALTH SERVICES PA

Informed Consent for Psychotherapy

 

Introduction:

The therapeutic relationship is a unique and personal contractual agreement. To ensure clarity and understanding, this document outlines the terms and expectations of our work together. Please read and indicate your consent by checking the box at the end of this document. If you have any questions, feel free to discuss them with us (ReachLink).

 

Therapeutic Process:

By seeking therapy, you have taken a positive step towards improving your mental health. The effectiveness of the treatment depends on your willingness to engage in the process. Some aspects of therapy may bring up unpleasant emotions, but we (ReachLink) will support you to the best of our ability and help you gain clarity about your thoughts, feelings, and patterns of behavior.

 

Confidentiality:

All session content and materials relevant to your treatment will be kept confidential. Exceptions to this confidentiality policy include:

 

If you pose a risk of serious harm to yourself or others.

 

If you have been abused, neglected, or exploited.

 

If you are ordered by a court of law to disclose information.

 

If you are being treated as part of a legal proceeding.

 

Occasionally, we may consult with other professionals to provide you with the best treatment. In this case, we will not disclose your name or any other identifying information.

 

Telehealth Consultation:

You understand that your healthcare provider wishes you to engage in a telehealth consultation. You understand that the video conferencing technology used for this consultation may not be the same as an in-person visit.

 

You understand that telehealth consultations have the potential benefits of easier access to care and the convenience of meeting from a location of your choosing. However, there are potential risks associated with this technology, including interruptions, unauthorized access, and technical difficulties. You understand that your healthcare provider or ReachLink can discontinue the telehealth consultation if the videoconferencing connections are inadequate.

 

Video Recording:

You understand that video recording during psychotherapy sessions may be used for quality improvement, training, or treatment planning purposes. Video recording is optional and requires separate consent from the patient. If you consent to video recording, you understand that the recordings will be kept confidential, and your identity will be kept anonymous. You understand that you have the right to revoke your consent to video recording at any time.

 

By checking the box below, you acknowledge that you have read and understood the informed consent policy above, including the video recording policy, and agree to it.

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

I, _______________________________, authorize __________________________________ to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future  transactions on my account.

Agreed upon charges are defined as services requested by you through the ReachLink client portal. 

Your card will be charged at the time of booking of your session, this allows us sufficient time to complete the charges or contact you in the event a charge doesn’t go through.

Cancellations within 24 hours are subject to a $30 fee.

Colorado

ReachLink is a mental health service provider committed to providing quality care to our clients. As a licensed, registered, or certified mental health professional under Article 245, we are regulated by the division and strive to maintain the highest level of standards in our practice.

As required by Colorado Stat. § 12-245-216, we are providing you with the following:

(a) Our name, business address, and business phone number.

ReachLink

 

3651 FAU BLVD

 

STE 400

 

Boca Raton, FL 33431

 

833-732-2489

(b) An explanation of the levels of regulation applicable to mental health professionals under Article 245, including the differences between licensure, registration, and certification. We will also provide you with a listing of any degrees, credentials, certifications, registrations, and licenses we hold or have completed, including the education, experience, and training we were required to satisfy in order to complete the degree, credential, certification, registration, or license.

Levels of Regulation Applicable to Mental Health Professionals in Colorado

A Licensed Clinical Social Worker must hold a master’s or doctoral degree from a CSWE-accredited graduate school of social work, practice as a social worker for at least two years under the supervision of a licensed clinical social worker, pass an examination in social work, and pass a jurisprudence examination.

A Licensed Social Worker must hold a master’s degree from a CSWE-accredited graduate school of social work, pass an examination in social work, and pass a jurisprudence examination.

A Clinical Social Worker Candidate, Psychologist Candidate, a Marriage and Family Therapist Candidate, a Licensed Professional Counselor Candidate, and an Addictions Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required experience and supervision hours for licensure.

A Licensed Marriage and Family Therapist must hold a master’s or doctoral degree in marriage and family counseling from an accredited program, have at least two years supervised post-master’s or one year post-doctoral practice, pass an examination in marriage and family therapy, and pass a jurisprudence examination.

A Licensed Professional Counselor must hold a master’s or doctoral degree in professional counseling from an accredited program, have at least two years post-master’s or one year postdoctoral supervised practice, pass an examination in in professional counseling, and pass a jurisprudence examination.

A Licensed Psychologist must hold a doctoral degree in psychology from an accredited program, have at least one year of post-doctoral supervised practice in psychology, pass an examination in psychology, and pass a jurisprudence examination. 

A Certified Addiction Technician must be a high school graduate or equivalent, complete 1,000 hours of supervised clinical experience over a minimum of six months, pass the national certification addiction counselor level 1 examination, and pass a jurisprudence examination. 

A Certified Addiction Specialist must hold a bachelor’s degree in a behavioral health concentration or human services equivalent from an accredited program, complete a minimum of 3,000 hours of supervised clinical experience over a minimum of 18 months, pass the national certification addiction counselor level II examination, and pass a jurisprudence examination.

A Licensed Addiction Counselor must hold a master’s or doctoral degree in the behavioral health sciences from an accredited program, have at least 2,000 hours of supervised direct clinical practice in the addiction field, pass the master addiction counselor examination, and pass a jurisprudence examination.

An Unlicensed Psychotherapist is a psychotherapist listed in the State’s database and is authorized by law to practice psychotherapy in Colorado, but is not licensed by the state and was not required to satisfy any standardized educational or testing requirements to obtain a registration from the state.

(c) A statement indicating that the practice of licensed or registered persons in the field of psychotherapy is regulated by the division. We will also provide you with an address and telephone number for the board that regulates us.

The practice of licensed or unlicensed registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Professions and Occupations. The Board of Social Work Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

(d) A statement indicating that:

(I) You are entitled to receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure;

(II) You may seek a second opinion from another therapist or may terminate therapy at any time;

(III) In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies us;

(IV) The information you provide during therapy sessions is legally confidential in the case of individuals licensed, certified, or registered pursuant to Article 245, except as provided in section 12-245-220 and except for certain legal exceptions that will be identified by us should any such situation arise during therapy.

 

(e) If we are an unlicensed psychotherapist, a statement indicating that we are authorized by law to practice psychotherapy in Colorado but are not licensed by the state and are not required to satisfy any standardized educational or testing requirements to obtain a registration from the state.

(f) A statement indicating that your records may not be maintained after seven years pursuant to section 12-245-226(1)(a)(II)(A).

If you are a minor who is consenting to mental health services pursuant to section 27-65-104, we will disclose the above information to you. If you are a minor whose parent or legal guardian is consenting to mental health services, we will disclose the above information to your parent or legal guardian.

In residential, institutional, or other settings where psychotherapy may be provided by multiple providers, we will provide the above information to you by the primary therapist. The institution will also provide you with a statement containing the information in subsections (1)(c) and (1)(d) of this section and a statement that you are entitled to the information listed in subsections (1)(a) and (1)(b) of this section concerning any psychotherapist in the employ of the institution who is providing psychotherapy services to you.

The disclosure of information required by subsection (1) of this section is not required when psychotherapy is being administered in any of the following circumstances:

(a) In an emergency;

 

(b) Pursuant to a court order or involuntary procedures pursuant to sections 27-65-106 to 27-65-110;

 

(c) The sole purpose of the professional relationship is for forensic evaluation;

 

(d) You are in the physical custody of the department of corrections, the department of human services, or the behavioral health administration in the department of human services, and such department or administration has developed an alternative program to provide similar information to you and the program has been established through rule; 

 

(e) The client is incapable of understanding the disclosure and has no guardian to whom disclosure can be made;

 

(f) By a social worker practicing in a hospital that is licensed or certified under section 25-1.5-103(1)(a)(I) or (1)(a)(II);

 

(g) By a person licensed or certified pursuant to this article 245 or by an unlicensed psychotherapist practicing in a hospital that is licensed or certified under section 25-1.5-103(1)(a)(I) or (1)(a)(II).

 

(5) If the client has no written language or is unable to read, an oral explanation shall accompany the written copy.

 

(6) Unless the client, parent, or guardian is unable to write, or refuses or objects, the client, parent, or guardian shall sign the disclosure form required by this section not later than the second visit with the psychotherapist.