HIPAA NOTICE OF PRIVACY PRACTICES

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

LifeStyle by Choice has been and will always be totally committed to maintaining client confidentiality.  I will only release healthcare/hypnosis or personal information about you in accordance with federal and state laws and professional ethics.

This notice describes our policies related to the use and disclosure of your healthcare information.

Use and disclosure of your health, counseling, and personal information is for the purpose of providing services.  Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care.  State and federal laws allow us to use and disclose your personal & health information for these purposes.

TREATMENT:  I may need to use or disclose health information about you to provide, manage or coordinate your care or related services.

PAYMENT:  As necessary I will provide information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes.  The person in your family who pays for your insurance may be the billing source. 

HEALTHCARE OPERATIONS:  We may need to use information about you to review our treatment procedures and business activity.  Information may be used for certification, compliance and licensing activities.

Other uses or disclosures of our information which do not require your consent:
There are some instances where we may be required to use and disclose information without your consent.  This may include but is not limited to:  Information you and/or your child or children report about physical or sexual abuse; then by Wisconsin State Law we are obligated to report this to the Department of Health Services.  Information provided by you that informs us that you are in danger of harming yourself or others.  Information to remind you about or to reschedule appointments or treatment alternatives.  Information shared with law enforcement if a crime is committed on our premises or against any staff, or as required by law such as a subpoena or court order. Basic information about you may be given out in order to collect monies owed.

CLIENT RIGHTS: Right to request how we contact you. It is normal practice to communicate with you at your home address and or the daytime phone number you gave us when you scheduled your appointment.  Sometimes I may leave messages on your voicemail.  You have the right to request that our office communicate with you in a different way. 
May I contact you by home phone?   YES _____    NO _____        May I contact you by cell phone?    YES _____    NO _____ 

Cell: _____ ____________________  Home: _____ ____________________  Other: _____ ____________________                                       


Right to release your medical records.
You may consent in writing to release your counseling or hypnotherapy records to others.  You have the right to revoke this authorization, in writing, at any time.  However, a revocation is not valid to the extent that we have acted in reliance on such authorization.

Right to inspect and copy your health, counseling and personal records.
You have the right to inspect and obtain a copy of your information contained in our records.  To request access to your billing or health information, contact Gary J. Coenen.  Under limited circumstance I may deny your request to inspect and copy.  If you ask for a copy of any information I may charge a reasonable fee for the costs of copying, mailing and supplies.

Right to add information or amend your records.
If you feel that information contained in our counseling record is incorrect or incomplete, you may ask to add information to amend the record.  I will make a decision on your request within 60 days or in some cases 90 days.  Under certain circumstances we may deny your request to add or amend information.    If your request is denied you then have the right to file a statement that you disagree.  Your statement and my response will be added to your record.  To request an amendment you must contact Gary J. Coenen.  We will require you to submit your request in writing and to provide an explanation concerning the reason for your request. There will be a $1.00 per page charge for each page requested.

Right to an accounting of disclosures.
You have the right to request an accounting of disclosures, if any, which is a list of certain disclosures such as child or elder abuse, disclosures related to suicidal or homicidal threats and disclosures to the U.S. Department of Health and Human Services to evaluate compliance. Or, disclosures to collect monies owed.

Right to request restrictions on uses and disclosures of your health, counseling, and personal information.
You have the right to ask for restrictions on certain uses and disclosures of your health, counseling / hypnosis or personal information.  This request must be submitted in writing to my office.  However, I am not required to agree to such a request.

Right to complain.
If you believe your privacy rights have been violated please contact me personally and we will discuss your concerns.  If you are not satisfied with the outcome you may file a written complaint with the U.S. Department of Health and Human Services.  An individual will not be retaliated against for filing such a complaint.

Right to receive changes in policy.
You have the right to receive any future policy changes secondary to changes in state and federal laws.  This can be obtained from Gary J. Coenen.

INFORMED CONSENT:

Thank you for choosing LifeStyle by Choice, Gary J. Coenen, MS, CSAC. We realize that starting counseling or Clinical Hypnosis is a major decision and you may have many questions.  This document is intended to inform you of our policies, State and Federal laws and your rights. If you have other questions or concerns, please ask and Gary will try his best to give you all the information you need.  Gary J. Coenen, MS, has earned a Master of Science degree in mental health, a certification in Clinical Hypnotherapy and Advanced Clinical Hypnotherapy and a certification in (NLP) Neuro-linguistic Programming as a Master Practitioner. He is also certified to do REIKI at the Master level.  He has extensively studied (EFT) Emotional Feeling Technique.  Gary is licensed in the state of Wisconsin for Clinical Substance Abuse Counseling. When working with addictions Gary uses hypnosis, cognitive-behavior therapy, as well as most other client centered therapies. Other treatment approaches are used depending on the person or condition.  Treatment practices, philosophy and plan limitations and risks will be discussed with you during your first appointment.

CONFIDENTIALITY AND EMERGENCY SITUATIONS:
Your verbal communication and clinical records are strictly confidential except for : a) information shared with consultants,  b) information (diagnosis and dates of service) shared with your insurance company to process your claims, c)  information you and/or your child or children report about physical or sexual abuse; then, by Wisconsin State Law, Gary is obligated to report this to the Department of Health Services, d) where you sign a release of information to have specific information shared, e) if you provide information that informs me that you are in danger of harming yourself or others, f) information necessary for case supervision or consultation, and g) when required by law.  If an emergency situation arises for which you or your guardian feels immediate attention is necessary, you or the guardian understands that they are to immediately contact the emergency services in the community (911) for those services.  Gary J. Coenen will follow those emergency services with standard counseling and support to you and / or your family as requested.  

FINANCIAL ISSUES:
You are asked to pay for each particular session unless other arrangements have been made.  You may pay by check, cash or credit card.  If your balance exceeds $300.00 we will need to ask that you pay for services when rendered.  After 60 days any unpaid balance will be charged 1.5% interest a month (18% APR).  In the event that your account is overdue and turned over to our collection agency, you or the responsible party will be held responsible for any collection fee charged to our office to collect the debt owed.  We ask that every client authorize payment of medical benefits directly to LifeStyle by Choice.  By signing below you submit that you have received a copy of the fee schedule.

Lastly, if you need to cancel or reschedule an appointment please give 24 hours advanced notice; otherwise you will be billed at the hourly rate for the appointment that you missed. Missed or no-show appointments will result in you being charged the full amount of the session booked unless the appointment can be filled. I sincerely appreciate your cooperation and if at any time you have any questions regarding fees, balances or payments please feel free to ask.  You may have a copy of this Informed consent if requested.

NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS:  I have read and received a copy of the Notice of Privacy and Client Rights document. 

Signature(s) ________________________________________ Date: __________              ________________________________________      Date: __________



CONSENT FOR TREATMENT OF CHILDREN OR ADOLESCENTS:

I/We consent that ______________________________________ may be treated as a client at the office of LifeStyle by Choice by Gary J. Coenen, MS.


Signature(s) ________________________________________ Date: __________                ________________________________________      Date: __________