In the event you conduct future counseling sessions with Stacey J. Nyman, LPC and Well Being, LLC via a tele-metal health or online video conferencing format, it is important you are aware and provide consent to the specifics regarding this format and use of video conferencing technology for your counseling sessions.

Video Conferencing for Online Tele-Mental Health Sessions:

All video conferencing and tele-mental health correspondences will be done through Counsol.com.  As a customer of Counsol.com I am a Covered Entity or a Business Associate as defined under the Health Insurance Portability and Accountability Act (HIPAA) and it will use Counsol.com services to create, receive, transmit, or maintain PHI, the customer must request a Business Associate Agreement (BAA) from Counsol.com. In this situation, Counsol.com will act as a Business Associate, and it will manage its HIPAA obligations accordingly.

Counsol.com is encrypted to the federal standard. Counsol.com was designed and built to support the workflow of healthcare providers and that includes following necessary rules and regulations associated with HIPAA.  Counsol.com complies with all these regulations.   Counsol.com enables Covered Entities, such as Well Being, LLC to be compliant with HIPAA in several ways:

Does not permanently store Protected Health Information

Operates according to the Privacy and Security Rules

Conducts risk analysis and management

Has disaster preparation plans in place

Partakes in ongoing training for all required staff

Has a Privacy and Security officer

Signs a Business Associates Agreement

Please understand there is a reasonable chance that communicating through electronic methods may be intercepted and eavesdropped on by a third party, including, but not limited to, family, co-workers, employers, and hackers.  At any time during your treatment, please feel free to ask any clarifying questions.

In the event a video conferencing vendor fails or there is reduced connectivity, the client will have the option to move to a voice to voice phone session or a Facetime/Skype session in which the therapist cannot extended HIPPA standards, nor has a Business Associate Agreement with the vendor(s).  In the event the client agrees to utilize these avenues for the session, the client holds the therapist harmless for any confidentiality breaches associated with the same.

Privacy Measures For The Client

It is recommended that you (the client) use the same safety measures that I use for keeping your personal health information (PHI) confidential.

Paper

It is recommended that you store all paper documents with you PHI in a locked cabinet.

When receiving distance counseling it is also recommended that you:

Conduct the sessions in a private location where others cannot hear you.

Using secure video conferencing technology

If the technology has a status bar, hide your status.

Do not record any sessions.

Password protect your computer, tablet, phone, and any other device with a password that is unique. 

Always log out of your sessions.

Do not have any software remember your password. Sign in every time.

Do not share your passwords with anyone.

Do not share your computer when you are logon to any counseling software.

If you wish to avoid others knowing that you are receiving counseling services, clear your browser's cache (browsing history), and on your phone, list your therapist by a name rather that as "counselor or therapist".

Do not download or store information off of your client portal Simplepractice.com.  However, if you do decide to, only store in on an encrypted file.

Have all of your devices set to time out requiring you to sign back in after a set idle time.

Keep your computer updated.

Use a firewall and antivirus program.

When online do not login as an administrator

Router / Access Point

Only use a secure network for internet access using a WAP2 security key.

Use your own administer ID and password (not the default) for your router or access point.

Choose a custom SSID name, not the default name.

Limit the range of you Wi-Fi by positioning it near the center of your home.

Notify you counselor if you suspect any breach in your security.

For more information on securing your mobile device visit: http://www.healthit.gov/providers-professionals/how-can-you-protect-and-secure-health-information-when-using-mobile-device

BY SIGNING THIS FORM, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO EACH OF THE ITEMS CONTAINED IN THIS DOCUMENT. IN ADDITION, CLICKING THIS BOX SERVES AS CONSENT TO TREAT/EVALUATE VIA AN ONLINE TELE-MENTAL HEALTH FORMAT.

Cancellation must be made 24 hours in advance or you will be charged for full session rate.

Notice of Policies and Practices to Protect the Privacy of Your Health Information

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

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

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

“PHI” refers to information in your health record that could identify you.

“Treatment, Payment and Health Care Operations”

Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example would be when I consult with another health care provider, such as your family physician or another psychologist.

Payment is when I obtain reimbursement for your healthcare. Examples are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
Health Care Operations are activities that relate to the performance and operation of my practice. Examples are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

“Use” applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

“Disclosure” applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, or 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 I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information.

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

III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse – If I have reasonable cause to believe that a child has been abused, I must report that belief to the appropriate authority.

Adult and Domestic Abuse – If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report that belief to the appropriate authority.

Health Oversight Activities – If I am the subject of an inquiry by the Georgia Board of Psychological Examiners, I may be required to disclose protected health information regarding you in proceedings before the Board.

Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release information without your written consent or a court order.

The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

Serious Threat to Health or Safety – If I determine, or pursuant to the standards of my profession should determine, that you present a serious danger of violence to yourself or another, I may disclose information in order to provide protection against such danger for you or the intended victim.

Worker’s Compensation – I may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

IV. Patient’s Rights and Counselor’s Duties
Patient’s Rights:
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.)

Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.

Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, I will discuss with you the details of the accounting process.

Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Counselor’s Duties:
I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
If I revise my policies and procedures, I will provide you with a revised notice at your next session.

V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me at 404-368-5552.

If you believe that your privacy rights have been violated and wish to file a complaint with me/my office, you may send your written complaint to me at 6740 Jamestown Drive, Alpharetta, GA 30005

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request.

I will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on June 1, 2010. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by the time of your next session.