This form is an agreement between you and me (Kathryn Blount, MA Ed., LCMHC #6934). The words “you” and “your” below can mean you, your child, a relative, or some other person if you have written his or her name here: ______________________________________________________________
When I diagnose, treat or refer you, I will be collecting what the law calls “protected health information” (PHI) about you. I need to use this information to decide on what treatment is best for you and to provide treatment to you. I may also share this information with others to arrange payment for your treatment, to help carry out certain business or government functions, or to help provide other treatment to you.
I can treat you only if you sign this form agreeing to my privacy practices. In the future, I may change how I use and share your information, and so I may change the notice of privacy practices. If I do change it, you can get a copy from my website (avlmindbody.com) or by calling me at 828-552-4780.
If you are concerned about your PHI, you have the right to ask me not to use or share some of it for treatment, payment, or administrative purposes. You will have to tell me what you want in writing. Although I will try to respect your wishes, I am not required to accept these limitations. However, if I do agree, I will promise to do as you asked. After you have signed this consent, you have the right to revoke it by writing to me. I will stop using or sharing your PHI, but I may already have used or shared some of it, and cannot change that.
By signing this form, you are agreeing to let me use your PHI and to send it to others for the purposes described above. Your signature below acknowledges that you have read the “HIPAA Notice” form that explains in more detail what your rights are and how I can use and share your information.
Client/Guardian Signature Date
Print Name Date