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Green Hills with Blue Sky

Privacy Policy and Confidentiality

Mental Health Privacy Practices/HIPAA 

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law (Public Law 104-191), passed by Congress in 1996 that, among other things, protects an individual's right to keep and/or transfer his or her health insurance when moving from one job to another and sets out certain administrative procedures, like ensuring the privacy of an individual's protected health information and providing security for electronic data sharing of protected health information.

As a therapist I am ethically and legally required to protect the confidentiality of my clients. Information will not be shared without written permission from the client or, if the client is a minor under the age of eighteen, the client's parent or legal guardian.

There are, however, conditions under which a client's confidentiality is released or not protected. These include: 

  • Suspected child abuse or dependant adult or elder abuse, for which the provider is required by law to report this to the appropriate authorities immediately.
  • If a client is threatening serious bodily harm to another person(s), the provider must notify the police and inform the intended victim.
  • If a client intends to harm himself or herself, the provider will make every effort to enlist the client's cooperation in ensuring their safety. If the client does not cooperate, the provider will take further measures without the client's permission that are provided by law in order to ensure the client's safety.
  • Information is released directly to the court for court-ordered evaluations or court testimony.

Please note: Insurance companies request that the client release information to them for certification of services or reimbursement.

My therapeutic visitation services are not considered to be therapy and are not bound by the confidentiality of therapy.  Information about what is said and done during therapeutic supervised visitaion will be provided to individuals and agencies such as Family Court that have a reason to have such information.


Notice of Privacy Practices


1. My commitment to you: I understand that the information I collect about you and your health and mental health is personal. Keeping that information confidential and secure is one of my most important responsibilities.

I keep a record of the care and services you receive from me.  I need this record to provide you with quality care and to comply with certain legal requirements. I am committed to protecting your health information and to following all state and federal laws regarding the protection of your health information.

This Notice of Privacy Practices describes how I may use and disclose your protected health information to carry out treatment and payment and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information,” is information about you that may identify you and that relates to your past, present or future physical or mental health condition or care.

You have the following rights by law:

♦ You have the right to inspect and obtain a copy of health/mental health information that may be used to make decisions about your care. Usually, this includes medical and billing records. It does not include information that is needed for civil, criminal, or administrative actions or proceedings. To inspect or obtain a copy of health information that may be used to make decisions about you, you must submit your request by email to Keith Jordan at [email protected]  I may charge a fee for the costs of copying, mailing, or other supplies associated with your request.  I may deny your request to inspect and obtain a copy in very limited circumstances.

♦ If you feel that the health information we have about you is incorrect or incomplete, you may ask us to amend that information. We may deny your request if you ask to amend information that: (1) was not created by me; (2) is not part of the health information kept by us; (3) is not part of the information which you would be permitted to inspect or copy; or (4) is determined to be accurate and complete. You have the right to request an amendment for as long as the information is kept by or for me.

To request an amendment, your request must be made to me by email. In addition, you must provide a reason that supports your request.

♦ You have the right to request a list of information releases that I have made of your health information The list will not include: health information releases that were made: (1) for purposes of providing treatment to you, obtaining payment for services, or releases made for other administrative or operational purposes; (2) for national security purposes; (3) to correctional and other law enforcement custodial situations; (4) based on your written authorization (5) to persons who are involved in your care; or (6) before April 14, 2003.

To request this list or accounting of disclosures, you must submit your request by email to me. Your request must state a time period, which may not be longer than 6 years. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12 month period will be free. For additional lists, I may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

♦ make sure that health information that identifies you is kept private

♦ give you this notice of our legal duties and privacy practices with respect to health information about you

♦ follow the terms of the notice that is currently in effect. If you have any questions about this notice, please contact

me by email.

2. Your Health Information Rights: You have the following rights regarding the health information we have about you:

♦ You have the right to request a restriction or limitation on the health information I use or disclose about you for the purpose of treatment, payment, or health care operations. You also have the right to request that I restrict or limit health information about you that I may use or disclose to someone who is involved in your care or the payment for your care, such as a family member. For example, you could ask that we not use or disclose information about the medication you are taking to your spouse or significant other.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. There is one exception to this: if you have paid for your treatment in full or out of pocket, and request a restriction on disclosures for payment or health care operations purposes to your health plan, we must agree to your request.

To request restrictions, you must make your request to me by email. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit my use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse).

♦ You have the right to request that I communicate with you about your health matters in a certain way or at a certain location. For example, you can ask that I only contact you at a certain phone number or by mail. To request confidential communications, you must make your request to me by email. I will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

♦ If there is a breach of your unsecured protected health information (which generally means your health information is not encrypted or otherwise can be read by anyone who looks at it), I must notify you that this has occurred.

♦ You have a right to a paper copy of this notice, which you may request at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.  To obtain a paper copy of this notice, contact me by email.  You may also obtain a copy of this notice at my website, www.keithjordanlcsw.com.

3. How we may use and disclose health information about you:

Your health information, which includes any information that relates to your past, present, or future health/mental health condition (which might include your photograph), may be used and released by me for the purposes of providing treatment to you, obtaining payment for services, for administrative and operational purposes, and to evaluate the quality of the services you receive. 

I may release information about you to your health plan or health insurance carrier to obtain payment for our services.

I may also share your information, when appropriate, with government programs such as Workers’ Compensation, Medicaid, Medicare, or Indian Health Services to determine if you are eligible for, or to coordinate, your benefits, entitlements, and payments. We may need to disclose a limited amount of information about you to explore your financial situation for possible sources of payment for your care, but we will only do so as permitted under law. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. 

I may use and release information about you to ensure that the services and benefits provided to you are appropriate and are high quality. For example, I may use your information to evaluate my treatment and service programs or to evaluate the services of other providers.

Unless you provide me with alternative instructions, I may contact you about reminders for treatment, medical care, or health check-ups. I may also contact you to tell you about health related benefits or services that may be of interest to you or to give you information about your health care choices. 

I will disclose health information about you when required to do so by federal, state, or local law or in response to a court order, subpoena, warrant, summons, or other similar process

I will notify the appropriate government authority if I believe a patient has been the victim of abuse, neglect or domestic violence; I will only make this disclosure if you agree or when required or authorized by law.


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