Information for Clients and Disclosure Statement – printable form
Notice of Privacy Practice
As required by the privacy regulation created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), this notice describes how health information about you and your child (as a client of my mental health counseling or art therapy practice) may be used and disclosed and how you can get access to you/your child’s individually identified health information.
I am committed to maintain the privacy of your/your child’s Protected Health Information (PHI). In conducting my business, I will create records regarding you/ your child and the treatment and services.
I may use and disclose your PHI in the following ways.
- Treatment – With your written consent, I may disclose and exchange your/your child’s PHI with other service providers and family members in order to support your/your child’s treatment. See the Consent For Disclosure and/or Exchange of PHI form.
- Payment – I may use and disclose your PHI in order to bill and collect payment from third parties (insurers) with your consent. See the Treatment Agreement Form for more details.
- Business Operations – I may use and disclose your/your child’s PHI to contact you for business purposes, for example, to remind you of an appointment. I may call your home or other alternate location and leave a message regarding appointments on voice mail. I may also mail correspondence to your home such as appointment reminder cards and payment statements.
Use and disclosure of your/your child’s PHI in Certain Special Circumstances are:
- In the event of medical emergency, emergency personnel or services may be given any necessary information.
- In the event of a threat to oneself or someone else, if that threat is perceived to be serious, the proper individuals must be contacted. This may include the individual against whom the threat is made.
- In the event of suspected child or elder abuse, the proper authorities must be contacted. The actions do not have to be witnessed to be reported.
- In certain select circumstances, judges can court order records of treatment
- Records must be released when subpoenaed by an attorney in Washington State unless you file a Protection Order within 14 days
- In the event of a patient’s death, the information may be released if the patient’s personal representative or the beneficiary of an insurance policy on the patient’s life signs authorizing disclosure
- If you bring a complaint against your therapist with the State of Washington Department of Health
Your Rights regarding your PHI:
- Confidential Communication; You have the right to request that our practice communicate with you/your child about your/your child’s health and related issues in a particular manner or at a certain location.
- Requesting Restrictions; You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations.
- Inspection and copies: You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you. You must submit your request in writing.
- Amendment: to request an amendment, your request must be made in writing.
- Right to file a complaint Complaints may be directed to Department of Health, HSQA Complaint, PO Box 47857, Olympia, WA 98504-7857, (360) 236-4700 http://www.doh.wa.gov/LicensesPermitsandCertificates/FileComplaintAboutProviderorFacility.aspx
- Right to provide an authorization for other uses and disclosure.
If you have any questions regarding this notice or my health information privacy policies, please contact Mineko Takada-Dill, (206) 276-4915.
Information for Clients and Disclosure Statement
Background and Experience
I am a Licensed Mental Health Counselor and Registered Art Therapist. I have been certified in Washington State since 1997 and licensed since 2001. I gained an M.A. in Art Therapy from New York University in 1992.and frequently attend continuing Education Seminars, including Ethnic Minority Certification Program. I have worked at Outpatient Substance/Alcohol Program in Brooklyn, NY, at the Community Mental Health Center of King County in Seattle, WA, and at Highline School District. I have been in private practice since 2001 and have held several school district contracts for student counseling.
How I practice
I have two different places to practice counseling and art therapy. In the counseling office I use art therapy with limited art supplies and use both psychodynamic and cognitive behavior therapies depending on my clients’ needs. In the studio, I primarily use art therapy and sand tray therapy.
I believe art therapy is a powerful medium to express ourselves. Our creative processes and final art works reflect our mind and help us to recognize our inner conflicts and/or problems and bring creative solutions. Feel free to discuss my approach and your treatment goals and progress.
My counseling and art therapy sessions are 60 minutes long. It is important that you be on time for your appointment, as it is not possible to extend your sessions beyond your scheduled appointment time. Your session time is reserved for you. If you are unable to keep your appointment for any reason, please give me 24-hour advance notice of cancelation, excluding weekends and holidays. If I don’t answer the phone, please leave a message on the voice mail. I don’t accept cancelation by e-mail even if you have signed the consent to allow us to have limited communication through e-mail. Appointments cancelled without 24 hours’ notice will result in a full fee charge for the session (the amount is indicated in the Fee section below).
I am a network provider for Premera, Regence, First Health, Life Wise and MHN. Frequently the insurance companies subcontract out with other insurance companies for Behavior Health (counseling) coverage, so please contact your insurance company prior to the intake session.
Insurance coverage for mental health services varies depending on your insurance company and its policy. You will need to sign the Authorization for Treatment Form which includes your consent to release your PHI to your insurance company prior to me contacting your insurance company or sending billing to them. Until I receive verification from your insurance company, you will be responsible for full payment at each session. If your insurance policy has a co-pay requirement, you will be responsible for your co-pay at each visit.
In case of an emergency during office hours, Mondays to Fridays between 9 am and 5 pm, you may reach me through my office number (206) 276-4915. I check for voice mails several times a day but I am not able to attend you immediately if I am with other clients. The 24-hour Crisis Line is available at (206) 461-3222.
As I discussed in Notice of Privacy Practice, I am dedicated to maintaining the privacy of your Protected Health Information (PHI). All information from sessions will remain confidential. The only way information may be released to any other party is through a specific Consent for Disclosure and/or Exchange of Protected Health Information (PHI) Form. If you choose to use third party coverage (medical insurance), your PHI will be released to your insurance company after you sign the Treatment Agreement Form. The law requires the release of confidential information without consent in certain select circumstances. Please read Notice of Privacy Practices.
As a licensed Mental Health Counselor, I am required to keep treatment records. If you would like NOT to keep treatment records, with the exception of you or your child’s name, payment method and date of services and disclosure form signed by you and Mineko Takada-Dill, MA,LMHC, please notify me in writing.
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