Some Notes on Confidentiality

Please note that the Therapeutic process is a very sacred and confidential transaction requiring absolute trust and confidentiality.

As such, it assures you that nothing can, or will ever be shared with others without your informed and explicit written consent.

Notwithstanding, Confidentiality may be, and WILL BE breached without your explicit authorization under the following eight conditions:

1. If there is a need to file for Insurance Reimbursement.
2. Under a Court Order signed by a Judge.
3. A physician has referred you, and/or your physician requires feedback.
4. You are here under a judicial order.
5. In case where there has been disclosure of abuse, or neglect, of children, or the elderly.
6. In case of confirmed domestic violence.
7. In cases where it is believed by the Therapist that the patient is at risk to do harm to themselves, or others.
8. In cases of extreme emergency where you are incoherent, under the influence of a substance, or seriously lacking in judgment and impulse control.

We are sure that at some point you had to sign an "Authorization" for your medical doctors, providing them with permission to communicate and exchange information with other doctors, hospitals, relatives, and insurance companies.
In a similar fashion, if you decide to seek our services, you will be required to sign a Hipaa form, that will authorize us to communicate with people, or entities that you feel comfortable with.

I (full name) * do hereby give my consent and authorize The American Board of Mental Health Diagnostics, aka: ABMHD, through any and all of its representatives, to receive or disclose the protected health information (‘‘PHI’’) described below, and to communicate via telephone, or in writing, and/or via E-Mail, and/or via Fax transmission with any and all providers of medical, and/or mental health, and/or academic service, or services, for myself, and/ or my dependent child.

This authorization for release of PHI will be covering the period of health care as follows:

a.   from today and until nine (9) months after my death, or

b.   from (date) to (date) or

c.    (event such as "discharge from treatment", "termination of treatment", "personal reasons" - please specify : )
at which time this authorization expires.

HIPAA Stipulations

Additionally, I do hereby authorize the release of PHI as follows (check one, or more):

The information may be used by Abmhd for Mental health assessment, diagnostics, treatment, or consultation, billing or claims payment, or other purposes as I may direct.

My complete health record (including records relating to (check as appropriate):

I understand that I have the right to revoke this authorization, in writing, at any time.

I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Hippa Consent

I give my consent and authorize The American Board of Mental Health Diagnostics, through any and all of its representatives to communicate via telephone, and/or in writing, and/or via E-Mail, and/or via Fax transmission with, the following

Please Note that children over the age of 14 MUST also sign this Authorization

My signature acknowledges my

By checking the "Agree" box, and/or through signing, I ackowledge that I have read and understood the above.

My signature acknowledges my understanding and agreement. _______________________________________________
Client, or Parent's/Guardian's Full Name *

Signature: _______________________________________