Notice of Privacy Practices
Lipscomb Family Therapy Center
Please provide your personal email address below. We ask that you use an email address that you do not share with anyone else and that only you can access. Thank you.
LIPSCOMB FAMILY THERAPY CENTER
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.
You have the right to: get a copy of your paper medical record, correct your paper medical record, request confidential communication, ask us to limit the information we share, get a list of those with whom we’ve shared your information, get a copy of this privacy notice, choose someone to act for you, and file a complaint if you believe your privacy rights have been violated.
You have some choices in the way that we use and share information as we: tell family and friends about your condition; provide disaster relief; include you in a hospital directory; provide mental health care; market our services and sell your information; and raise funds.
We may use and share your information as we: treat you; run our organization; bill for your services; help with public health and safety issues; do research; comply with the law; respond to organ and tissue donation requests; work with a medical examiner or funeral director; address workers’ compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.
CONSENT OF ELECTRONIC SIGNATURE
In an attempt to expedite the verification process, Lipscomb University and the LFTC ask that you, the client, read and sign this Notice of Privacy Practices electronically before receiving therapy at the LFTC.
The electronic signature process requires all documents to be sent through your personal email account specified in this consent form.
ELECTRONIC SIGNATURE AGREEMENT
By selecting the "I accept" button below and inserting your name, initials, email and date at the bottom of this Notice of Privacy Practices, you acknowledge and agree that you are signing this Notice of Privacy Practices electronically and agreeing to its terms and conditions. You acknowledge and agree that your electronic signature is the legal equivalent of your manual/handwritten signature on this Notice of Privacy Practices. By selecting "I accept" using any device, means or action, you consent to the legally binding terms and conditions of this Notice of Privacy Practices. You further acknowledge and agree that inserting your name, initials, email address and date at the bottom of this Notice of Privacy Practices (hereafter referred to as your "E-Signature") is as valid and legally enforceable as if you manually signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Lipscomb University and Lipscomb Family Therapy Center. You acknowledge and agree that you are the client authorized to enter into this Notice of Privacy Practices.
By selecting “I accept” below, you acknowledge and agree to all of the terms and conditions in this section, ELECTRONIC SIGNATURE AGREEMENT.
CONSENT TO ELECTRONIC DELIVERY
By selecting the “I accept” button below, you specifically agree to receive, obtain, and/or submit any and all LFTC documents and information electronically. These documents and information will be collectively known as Electronic Medical Records (“EMR”), and may include information about your reasons for seeking therapy, a description of the ways in which your problems impact your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that LFTC receives from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone. You acknowledge and agree that you are able to use your personal email account specified below and are able to retain electronic communications by printing and/or downloading and saving this Notice of Privacy Practices and any other agreements, electronic communications, documents, or records that are signed using your E-Signature. You accept such electronic communications provided via email as reasonable and proper notice for the purpose of fulfilling any and all rules and regulations, and agree that such electronic communications fully satisfy any requirement that communications be provided to you in writing or in a form that you may keep. We recommend that you print a copy of this Notice of Privacy Practices for future reference. You acknowledge and agree that you will keep or maintain all electronic communications records, including this Notice of Privacy Practices, and print or make an electronic copy of all such records.
You have the right to withdraw and revoke your consent to submit communications via your personal email at any time. By selecting “I accept” below, you acknowledge and agree that you are aware that any such revocation may delay the process of reviewing your medical record. If you wish to withdraw and revoke your consent, you must contact the LFTC director, office manager, therapists, or other staff.
By selecting “I accept” below, you acknowledge and agree to all of the terms and conditions in this section, CONSENT TO ELECTRONIC DELIVERY.
You are responsible for installation, maintenance, and operation of your computer, browser and software. Lipscomb University and LFTC are not responsible for errors or failures due to any malfunction of your computer, browser or software. Lipscomb University and LFTC are also not responsible for computer viruses or related problems associated with use of an online system. Your E-Signature indicates that you have access to the Internet, an email account capable of receiving communication from Lipscomb University and LFTC and appropriate software to review any and all electronic communications (e.g., a .pdf reader).
You may not sign/e-sign a Lipscomb University and LFTC document or transaction, including this Notice of Privacy Practices, on behalf of another individual, unless you have been granted specific, written and legal authority to do so by that individual or by a court of competent jurisdiction.
You agree to report any suspected fraudulent activities related to electronic signatures immediately to the LFTC director, office manager, therapist, or other staff.
You acknowledge and agree that if you falsify an electronic signature, you may be subject to appropriate civil or criminal penalties or proceedings under applicable federal and state laws.
Because of the nature of federal, state, and institutional guidelines affecting mental health and relationship care services, the information contained in this Notice of Privacy Practices is subject to change. You agree to indemnify, hold harmless and release LFTC, Lipscomb University and its trustees, agents and employees from and against any and all losses, damages, claims, demands and actions arising from or related to any changes made to this Notice of Privacy Practices.
By selecting “I accept” below, you acknowledge and agree to all of the terms and conditions in this section, MISCELLANEOUS.
You can ask to see or get a paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
Since you pay for a service or health care item out-of-pocket in full, we do not share that information for the purpose of payment or our operations with your health insurer.
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
You can complain if you feel we have violated your rights by contacting us using the information above. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to
200 Independence Avenue, S.W., Washington, D.C. 20201,
We will not retaliate against you for filing a complaint.
By selecting “I accept” below, you acknowledge and agree to all of the terms and conditions in this section, YOUR RIGHTS.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described in the following, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: share information with your family, close friends, or others involved in your care; share information in a disaster relief situation; include your information in a hospital directory.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: marketing purposes, sale of your information, and most sharing of psychotherapy notes. In the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again.
By selecting “I accept” below, you acknowledge and agree all of the terms and conditions in this section, YOUR CHOICES
OUR USES AND DISCLOSURES
How do we typically use or share your health information? We typically use or share your health information in the following ways. We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
. We can share health information about you for certain situations such as: preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; preventing or reducing a serious threat to anyone’s health or safety. We can use or share your information for health research. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. We can share health information about you with organ procurement organizations. We can share health information with a coroner, medical examiner, or funeral director when an individual dies. We can use or share health information about you: for workers’ compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; and for special government functions such as military, national security, and presidential protective services. We can share health information about you in response to a court or administrative order, or in response to a subpoena.
We are required by law to maintain the privacy and security of your personally identifiable health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see:
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Effective Date of this Notice: March 25, 2020
LFTC Clinic Director:
Justin G. Briggs, Ph.D.
Director of the Lipscomb Family Therapy Center
Note: We will never market or sell personal information. We will never share any substance abuse treatment records without your written permission.
By selecting “I accept” below, you acknowledge and agree all of the terms and conditions in this section, OUR USES AND DISCLOSURES
CLIENT AUTHORIZATION FOR USE OF MEDICAL INFORMATION
I, the client, have fully read and agree to the terms outlined in this NOTICE OF PRIVACY PRACTICES and give consent for treatment under these terms and conditions. I have discussed any questions I had with my therapist or therapist intern and/or Lipscomb Family Therapy Center staff and I understand the information in this Notice of Privacy Practices. I acknowledge that I have received a copy of the Notice of Privacy Practices at the Lipscomb Family Therapy Center. I understand that this notice describes how medical information about me may be used and disclosed and how I can get access to this information. Furthermore, I understand that the LFTC will abide by the above mentioned policies, procedures, and techniques in providing my treatment and managing my medical information. I hereby hold harmless and release Lipscomb University and all its trustees, agents and employees from and against any and all losses, damages, claims, demands and actions arising from or related to any breach of privacy or confidentiality in connection therewith.
By selecting “I accept” below, you acknowledge and agree to all of the terms and conditions in this section, CLIENT AUTHORIZATION FOR USE OF MEDICAL INFORMATION
By inserting my name, initials, email address and date below, I hereby acknowledge and agree that I have read and understood this Consent Form, am at least 18 years old and fully competent, and have executed the same as my own free will.
(Parents signing this form on behalf of any of their minor children will put their name and email information, not the minor child's name and email information, in the following "Client First Name," "Client Middle Initial," "Client Last Name," "Initials," and "Client Email Address" sections.)
Client First Name
Client Middle Initial (if applicable)
Client Last Name
CLIENT EMAIL ADDRESS
ADDITIONAL CLIENT INFORMATION
Client Phone Number
Client Street Number (e.g., 123 Main St)
We want to thank you for taking the time to complete this form. Please feel welcome to contact Lipscomb Family Therapy Center with any additional questions you may have. We look forward to working with you.
A copy of your responses will be emailed to the address you provided.
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of Lipscomb University.