Explanation of Forms: Your social worker, Shauna Lee Tepper, MSW, LISW-S, handles medical and clinical information about you, and law regulates how that information is handled. To comply with the law, Shauna Lee Tepper asks you to receive this notice and sign an authorization form.

Shauna Lee Tepper, is allowed by law to use and disclose information about you for the purposes essential to providing care (ie. treatment, payment collection) with your written consent.

An authorization allows Shauna Lee Tepper to not use and disclose information about you for any other reason than is listed in the authorization. Shauna Lee Tepper may not refuse to treat you for refusing to sign the authorization. Other rules about your rights regarding medical information are described in this notice.

Types of Uses and Disclosures: Medical information about you may be used or disclosed by this mental health clinician to help facilitate treatment, payment, and health care operations. Treatment includes consultation, diagnosis, provision of care and referrals. Payment includes all those things necessary for billing and collection, such as claims processing. Some examples of disclosures and use are below. This information would only be released with the client's written permission.

Example of Treatment Disclosure: Shauna Lee Tepper may disclose medical  information about you to your treating physician, a hospital or other providers to help them diagnose and treat an illness or injury.

Example of Payment Disclosure: Shauna Lee Tepper may disclose medical information about you when health plans or insurers, or other payers require information before paying for your health care services.

Other Uses and Disclosures: Your social worker may use or disclose your protected  health information in the following situations without your authorization. These situations include:

As required by/aw: Your counselor may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the  relevant requirements of the law. You will be notified, as required by law, of any such disclosures.

• Abuse or Neglect: Your counselor may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect, In addition, your counselor may disclose your protected health information if they believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
• Legal Proceedings: Your counselor may disclose protected health information in the course of a judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly  authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
• Law Enforcement: Your counselor may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes, These law enforcement purposes include: (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the  event that a crime occurs on the premises of the private practice of Shauna Lee Tepper and (6) medical emergency (not on the premises of the office of Shauna Lee Tepper and it is likely that a crime has occurred.
• Your counselor may use or disclose your protected health information if you are an inmate of a correctional facility and your counselor created or received your protected health information in the course of providing care to you.
• Criminal Activity; Consistent with applicable federal and state laws, your counselor may disclose your protected health information, if they believe that use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of self, another person or the public. Information necessary to ensure your safety or the safety of others may be disclosed to law-enforcement officers, potential targets of violence or others as required by  law. Your counselor may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
• Workers' Compensation: Your protected health information may be disclosed by Shauna Lee Tepper as authorized by the client to comply with worker compensation laws and other similar legally established programs.

With your written authorization your social worker may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care.

Restrictions: You have the right to request restrictions on the use and disclosure of medical information about you. 

Confidentiality: You have the right to have Shauna Lee Tepper, use only confidential means of communicating with you about clinical information. This means you may have information delivered to you at a certain time or place, or in a manner that keeps your information confidential,

Access- You have the right to see and receive a copy of information about you kept by Shauna Lee Tepper, under most circumstances,

Amendment: You have the right to have Shauna Lee Tepper amend records of information about you. Your counselor may refuse to amend information that is accurate, that was created by someone else, or is not disclosable to you.

Copy: You have the right to receive a paper copy of this notice.

Privacy Notice: Shauna Lee Tepper, is required by law to keep medical information about you private and to give you this notice. They must abide by this notice; however, your counselor reserves the right to amend this notice and make such change applicable to all clinical/medical information maintained by your counselor.

Effective Date: This notice is effective from October 1st 2021 until revised by Shauna Lee Tepper.