Henriette Kellum


Please be aware that a new federal law (HIPAA, 45 CFR § 164 et. seq.) went into effect on April 14, 2003. The purpose of this law is to define and regulate how private information about you is handled and protected. It might have an impact on the way you and I will communicate. Please familiarize yourself with my Notice of Privacy Practices section.

"Notice of Privacy Practices"

This notice involves your privacy rights and describes how information about you may be disclosed, and how you can obtain access to this information. please read it carefully.

I. Confidentiality

As a rule, I will disclose no information about you, or the fact that you are my client, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any evaluations I do. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, I do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing a general consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time by contacting me.

II. "Limits of Confidentiality"

Possible Uses and Disclosures of Mental Health Records without Consent or Authorization: There are some important exceptions to this rule of confidentiality - some exceptions created voluntarily by my own choice, and some required by law. If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits. We will discuss these issues now, but you may reopen the conversation at any time during our work together.

I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required:

III. Patient's Rights and Provider's Duties:

Complaints: If you believe your privacy rights have been violated, you may file a complaint with the U.S. Department of Health and Human Services. Information on how to do this is on their website: http://www.hhs.gov/ocr/hipaa/. You may also contact them at the following : Office for Civil Rights

U.S. Department of Health & Human Services
150 S. Independence Mall West - Suite 372
Philadelphia, PA 19106-3499
(215) 861-4441; (215) 861-4440 (TDD)
(215) 861-4431 FAX

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