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Privacy Policy

Client consent to Use and Disclosure of Protected Health Information
(HIPAA Privacy Notice)

I understand that as part of my health care for myself or as legal guardian for client, Four Elements Therapy, PLLC originates and maintains paper and/or electronic records describing health history, symptoms, diagnoses, treatment, and any plans for future care or treatment. This information is called


Protected Health Information
As part of providing services to you, we will collect information about your health care. We need this information to provide you with quality services and to comply with certain legal requirements. This notice applies to all the records of your care generated at or located at Four Elements Therapy, PLLC The law requires us to:

  1.  Make sure that information that identifies you is kept private;

  2. Give you this notice of our legal duties and privacy practices with respect to information
    about you; and

  3. Follow the terms of the Notice that is currently in effect.

How We May Use and Disclose Information about You:
Listed below are several reasons or ways in which information about you might be disclosed. In each category we will explain what we mean and give an example. NOT EVERY USE OR DISCLOSURE IN A CATEGORY WILL BE LISTED. The ways we might disclose information include:

  1. For Treatment: We may disclose information about you to any personnel at Four Elements Therapy, PLC or outside of Four Elements Therapy PLLC who are involved in your care. For example, your direct care staff may need to share information about your medications with your psychiatrist, or with your case manager.

  2. For Payment: We may use and disclose information about you so that services may be billed, and payment may be collected from you, an insurance company, or a government health program. We may also tell your health plan about a service you may receive to obtain prior approval or to determine whether your health plan will cover the treatment.

  3. For Health Care Operations: We may use information about you to run our program and to make sure you receive quality services, or to decide if we should change or modify our services.

  4. As Required by Law: We will disclose information about you required by federal, state, or local law. For example, we may reveal information about you to the proper authorities to report suspected abuse or neglect

  5. To Avoid a Serious Threat to Health or Safety: We may use or disclose information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person


I understand and have been provided with a Notice of Information Practices that provides a

more complete description of information uses and disclosures. I understand I have the
following rights and privileges:

* The right to review the notice prior to signing this consent,
* The right to object to the use of health information for directory purposes (such as service
areas/types of diagnoses treated) and
* The right to request restrictions as to how health information may be used or disclosed to
carry out treatment, payment, or health care operations.

I understand Four Elements Therapy, PLLC is not required to agree to the restrictions requested. I understand I may revoke this consent in writing, except to the extent that the organization has already acted in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to provide treatment as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand Four Elements Therapy, PLLC reserves the right to change their notice and practices prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Four Elements Therapy, PLLC change their notice, they will send a copy of any revised notice to the address I have provided. I understand that as part of this organization's treatment, payment, or health care operations, it may become necessary to disclose protected health information to another entity (such as to an insurance company), and I consent to such disclosure for these permitted uses, including
disclosures via fax. I understand I have the right to revoke this CONSENT provided I do so in writing, except to the extent that Four Elements Therapy, PLLC has already used or disclosed the information in reliance on this CONSENT.

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