Libratum Counseling, LLC                                                        142 W. Market St., 2nd Floor        

610.616.5890                                                                West Chester, PA 19382

Privacy Practices

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

Libratum Counseling, LLC provides outpatient mental health and behavioral health services.  As individual therapists we have a legal responsibility under the laws of the United States and the state of Pennsylvania to keep your health information private.  Part of our responsibility is to give you this notice about the privacy practices.  Another part of our responsibility is to follow the practices in this notice.  This form is effective January 1, 2019.  

Uses and Disclosures for Treatment, Payment and Health Care Operations:

Libratum Counseling, LLC may use or disclose your protected health information (PHI) for treatment, payment and health care operations with your consent.  To help clarify these terms, here are some definitions:

Uses and Disclosures Requiring Authorization:

Libratum Counseling, LLC may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained,  An “authorization” is written permission above and beyond the general consent that permits only specific disclosures.  In those instances when asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information.

Libratum Counseling, LLC will also need to obtain an authorization before releasing your psychotherapy notes.  “Psychotherapy notes” are notes that are made about our conversation during a private, group, joint, or family counseling session, which have been kept separate from the rest of your medical record.  These notes are given a greater degree of protection than PHI.  We do not necessarily keep psychotherapy notes on all patients or for all sessions.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing.  You may not revoke an authorization to the extent that (1) we have relied on that authorization, or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

Uses and Disclosure with Neither Consent nor Authorization:

We may use or disclose PHI without your consent or authorization in the following circumstances.

Your Rights Regarding Your PHI:

Grievance Procedures: Right to File a Complaint

If you are not pleased with your care or feel your PHI was not kept confidential you may officially file a grievance with us.  Under the DCS grievance procedure, we will work with you to address your questions, concerns and complaints.  The HIPPA Privacy Regulations also entitle you to file a complaint with the U.S. Secretary of Health and Human Services.  To file a complaint or learn more about the grievance process, you may contact Libratum Counseling, LLC at 610.616.5890, by mail at 142 W. Market Street, 2nd Floor, West Chester, PA 19382 or email at mmarkowitzlcsw@gmail.com.  There will not be any retaliation against you for filing a complaint.  

Signature:__________________________________________________________     Date:___________________________