HIPAA Consent Form

Consent to Use and Disclose Health Information

This consent form is required, according to Federal HIPAA regulations, for us to provide services. It documents agreement with the NPP form. This form is an agreement between you and Working Towards a Brighter Future INC. For the purposes of this consent form, the word “you” below may refer to you, your child, a relative or another person if you have written his or her name here . When we, or any associated with this office, provides examination, testing, diagnosis, treatment, or referral for you, this will include the collection of what the law called Protected Healthcare Information (PHI) about you.

This information is necessary to decide what treatment is best and to provide it. This information may be shared with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions. By signing this form, you are agreeing to allow the use of your information here or with others as is explained in more detail in the Notice of Privacy Practices (NPP). It also details your rights.

Your consent to this form approves the practices detailed in the NPP summary and full NPP. In the future we may change some of these policies. If so, it would be described in a new NPP. You can get a copy by asking us or by phone or in writing. If you have concerns about some of your information, you have the right to ask us to not use or share some of your information for treatment, payment or administrative purposes. You would have to communicate in writing what you are asking. After receiving it, although we are not required to agree to the request, we will let you know if we can agree to the limitations. If we agree, we will do our best to do what you asked. After you have signed this consent, you have the right to revoke it by writing a letter to Dr. Sheena Smith, LPC, informing us that you no longer consent. We would no longer be able to provide treatment, because of our requirement to have a signed consent form to provide services.

If we receive such a revocation of this consent, we will comply with your wishes about using or sharing your information from that time on, but we may already have used or shared some information in accord with this consent and of course would not be able to change that.