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Pompeyo Tabarez, MFT

Marriage Family Therapist MFC # 4932684

729 Main St, Ste. 101

El Centro, CA 92243

Ph. 760-355-1549 – Fax 760-355-8204

Therapy is a relationship that works in part because of defined rights and responsibilities held by the client and the therapist. As a client in counseling, you have rights that are important for you to be aware of, because this is your therapy, whose goal is your well-being.

I. Confidentiality:

The confidentiality of your personal health information is very important to me. Your health information includes records that I create and obtain when I provide you care, such as records of your symptoms, examinations, test results, diagnoses, treatments and referrals for further care. It also includes bills, insurance claims, or other payment information that I maintain related to your care.

I will always act so as to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you chose, and you can change your mind and revoke that permission at any time. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).

Generally speaking, I am required to:

· Maintain the privacy of your health information as required by law;

· Provide you with this informed consent of my duties

· Follow the terms of my notice currently in effect.

II. Uses and Disclosures of Information

Under federal law, I am permitted to use and disclose personal health information without authorization for treatment, payment, and health care operations. However, the American Psychiatric Association’s Principles of Medical Ethics or state law requires to obtain your express consent before we make certain disclosures of your personal health information.

Examples of using or disclosing your health information:

· I will submit a bill to your health insurer to receive payment for your care; the insurer asks for health information (for example, your diagnosis and what care I provided) in order to pay me. In such situations, I will disclose only the minimum amount of information necessary for this purpose.

· In the course of providing treatment to patients, I perform certain important functions such as quality assessment, training programs, credentialing, medical review, etc. In performing such functions, I may rely on certain business colleagues to assist me. I will only share the minimum amount of personal health information necessary for them to assist me.

III. Other uses and disclosures

There are some legal exemptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect. I may also use and disclose your personal information without authorization for the following additional purposes:

1. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality. I am not obligated to do this, and would explore all other options with you before I took this step.

2. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I may disclose health information about you to a state or federal agency to report suspected abuse, neglect, or domestic violence.

3. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.

4. If you and your partner decide to have some individual sessions as part of the couple’s therapy, what you say during such individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. I recommend you not to tell me anything you wish kept secret from your partner. I will remind you of this policy before beginning such individual sessions.

Record-keeping/Psychotherapy Notes

During the course of your care with me, you may receive treatment from a counselor, who keeps notes during the course of your therapy sessions about your conversations. These notes do not include basic information such as your medication treatment record, counseling session start and stop times, the types of frequencies of treatment you receive, or your test results.

IV. Other Rights

I’m always willing to discuss how and why I’ve decided to do what I’m doing, and to look at alternatives that might work better. You have the right to ask questions about what happens during therapy. You can request that I refer you to someone else if you decide I’m not the right therapist for you.

V. To File a Complaint

If you believe your privacy rights have been violated, you may file a written complaint by mailing it or delivering it to me. You may complain to the Secretary of Health and Human Services (HHS) by writing to Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201; by calling 1-800-368-1019; or by sending an email to [email protected].

VI. Your Responsibility as a Client

You are responsible for coming to your session on time and at the time we have scheduled.If you miss a session without canceling, or cancel with less than forty-eight (48) hours notice within business hours (Monday-Friday), you will be charged for that session.

VII. FEES

Individual therapy or couples therapy is $110 per 45-50 minute session. It is the policy of this office to request payment at the time services are provided unless other arrangements are made in advance. I am available to assist in the billing of your insurance carrier. The fee for services provided to you, the client, is part of a contract between you and this office. Therefore, you will be responsible for the fees, including those not paid for any reason by your insurance carrier.

Client Consent to Psychotherapy

I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality, the fee per session and my rights and responsibilities as a client, and my therapist’s responsibilities to me. I know I can end therapy at any time I wish.

Signed:__________________________________________________

Dated:___________________________________________________