Mandatory Disclosure and Other Documentation

Mandatory Disclosure/Informed Consent/HIPPA Information
Licensed Psychologist: Colo. License # 1934
A licensed psychologist must hold a doctorate degree in psychology and have at least 1 year of post-doctoral supervision. Regulatory requirements applicable to mental health professionals: Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, Licensed
Professional Counselor must hold a masters degree in their profession, have two years of
post-masters supervision. Licensed Social Worker must
hold a masters degree in social work.  Psychologist Candidate, Marriage and Family
Therapist Candidate, Licensed Professional Counselor Candidate must hold the
necessary licensing degree, be in the process of completing the required supervision for
licensure. Certified Addiction Counselor I (CAC I) must be a high school graduate,
complete required training hours and 1000 hours of supervised experience. A CAC II must
complete additional required training hours, 2,000 hours of supervised experience. A
CAC III must have a bachelors degree in behavioral health, complete additional required
training hours, 2,000 hours of supervised experience. Licensed Addiction Counselor
must have a clinical masters degree, meet the CAC III requirements. 
The practice of both licensed and unlicensed persons and certified school psychologists in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Psychologist Examiners address and telephone for the board is below:
1560 Broadway, Suite 1350, Denver, CO 80202, Phone # 303-894-7800
You are entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known, and the fee structure. You may seek a second opinion from another therapist or may terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board or regulatory agency responsible with regard to the practice of psychotherapy and psychologists. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a certified school psychologist, a licensed psychologist, a licensed clinical social worker, a licensed professional counselor, a licensed marriage and family therapist, or a registered psychotherapist. If the information is “legally confidential”, the therapist cannot be forced to disclose the information without the client’s consent. HOWEVER: There are exceptions to the general rule of legal confidentiality. In other words, confidentiality or privacy can not be guaranteed in all circumstances. Changes to Duty to Warn Statute; Due to past events in the news in which persons were killed in public places, such as a theater, the Colorado Legislature revised the Duty to Warn Statute,C.R.S.13-21-117. The revision was signed into law on April 1st". A copy of the revised statute is attached. The primary change was done to make it clear that a threat to a specific facility, or location, fell within the duty to warn. The original statute stated that there is a duty to warn: where the patient has communicated to the mental health care provider a serious threat of imminent physical violence against a specific person or persons. According to the revised statute, there is a duty to warn : where the patient has communicated to the mental health provider a serious threat of imminent physical violence against a specific person or persons, including those identifiable by their association with a specific location or entity. Thus, the change attempts to make it clear that if, for example, a patient says he is going to go and shoot people at a certain theater, there is a duty to warn, even if no people are personally identified. When there is a duty to warn, the mental health provider:  shall make reasonable and timely efforts to notify the person or persons. or the person or persons responsible for the specific location or entity that is specifically threatened. The requirement to notify the police or to take other appropriate action has not changed. Be sure to read the entire attached statute. 13-21-117. Civil liability - mental health providers - duty to warn - definitions. (1) As used in this section, unless the context otherwise requires: (a) "Mental health provider" means a physician, social worker, psychiatric nurse, psychologist, or other mental health professionals, or a mental health hospital, community mental health center or clinic, institution, or their staff. (b) "Psychiatric nurse" means a registered professional nurse as defined in section 12-38- 103 (11), CR.S., who by virtue of postgraduate education and additional nursing preparation has gained knowledge, judgment, and skill in psychiatric or mental health nursing. (2) (a) A mental health provider is not liable for damages in any civil action for tenure to warn or protect a specific person or persons, including those identifiable by their association with a specific location or entity, against the violent behavior of a person receiving treatment from the mental hearth provider, and any such mental health provider must not be held civilly liable for failure to predict such violent behavior except where the patient has communicated to the mental health provider a serious threat of imminent physical violence against a specific person or persons, including those identifiable by their association with a specific location or entity. (b) When there is a duty to warn and protect under the provisions of paragraph (a) of this subsection (2), the mental health provider shall make reasonable and timely efforts to notify the person or persons, or the person or persons responsible for a specific location or entity, that is specifically threatened, as well as to notify an appropriate law enforcement agency or to take other appropriate action, including but not limited to hospitalizing the patient. A mental health provider is not liable for damages in any civil action for warning a specific 
person or persons, or a person or persons responsible for a specific location or entity, 
against or predicting the violent behavior of a person receiving treatment from the mental 
health provider. (e) A mental health provider must not be subject to professional discipline when there is a duty to warn and protect pursuant to this section. (3) The provisions of this section do not apply to the negligent release of a patient from any mental health hospital or ward or to the negligent failure to initiate involuntary seventy- two-hour treatment and evaluation after a personal patient evaluation determining that the person appears to have a mental illness and, as a result of the mental illness, appears to be an imminent danger to others. 
Mandatory Elder Abuse Reporting 1) (a) On and after July 1, 2014, a person specified in paragraph (b) of this subsection (1) who observes the abuse or exploitation of an at-risk elder, or who has reasonable cause to believe that an at-risk elder has been abused or has been exploited or is at imminent risk of abuse or exploitation, shalf report such fact to a law enforcement agency not more than twenty-four hours after making the observation or discovery. (b) The following persons, whether paid or unpaid, shall report as required by paragraph (a) of this subsection (1): (1) Physicians, surgeons, physicians' assistants, osteopaths, physicians in training, podiatrists, occupational therapists" and physical therapists; (111) Registered nurses, licensed practical nurses, and nurse practitioners; VII) Psychologists and other mental health professionals; According to the Definitions section, 18.6.5-102: "At-risk elder" means any person who is seventy years of age or older. Also according to that section: (1) "Abuse" means any of the following acts or omissions committed against an at- risk elder: (a) The non-accidental infliction of bodily injury, serious bodily injury, or death; (b) Confinement or restraint that is unreasonable under generally accepted caretaking standards; (c) Subjection to sexual conduct or contact classified as a crime under this title; and d) Caretaker neglect. (5) "Caretaker" means a person who: a) Is responsible for the care of an  . . at-risk elder as a result of a family or legal relationship; b) Has assumed responsibility for the care of fin ... at-risk elder; or (c) Is paid to provide care or services to an ... at- risk elder. (6) "Caretaker neglect" means neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, or supervision is not secured the degree of care that a reasonable person in the same situation would exercise; except that the withholding, withdrawing, or refusing of any medication, any medical procedure or device, or any treatment, including but not limited to resuscitation, cardiac pacing, mechanical ventilation, dialysis, and artificial nutrition and hydration, in accordance with any valid medical directive or order or as described in a palliative plan of care shall not be deemed caretaker neglect. As used in this subsection (6), "medical directive or order" includes but is not limited to a medical durable power of attorney, a declaration as to medical treatment executed pursuant to section 15-18- 104, CR.S., a medical order for scope of treatment form executed pursuant to article 18. 7 of title 15f C R.5., and a CPR directive executed pursuant to article 18.6 of title 15, CR.S. (10) "Exploitation II means an actor omission committed bve person who: (a) Uses deception, harassment, intimidation, or undue influence to permanently or temporarily deprive an at-risk elder of the use, benefit, or possession of his or her money, assets, or property; (b) In the absence of legal authority: (1) Employs the services of a third party for the profit or advantage of the person or another person to the detriment of the at-risk elder; or (II) Forces, compels, coerces, or entices an at-risk elder to perform services for the profit or advantage of the person or another person against the will of the at-risk elder; or (e) Misuses the property of an at-risk elder in a manner that adversely affects the at-risk elder's ability to receive health care or health care benefits or to pay bills for basic needs or obligations. (13) "Undue influence" means the use of influence by someone who exercises authority over an at-risk elder in order to take unfair advantage of the at-risk elder's vulnerable state of mind, neediness, pain, or agony .... The "urged" to report statute continues to apply to other at-risk adults. C.R.S. 26-3.1-102. COLORADO REVISED STATUTES TITLE 18. CRIMINAL CODE ARTICLE 6.5. WRONGS TO AT-RISK ADULTS C.R.S. 18-6.5-108 (2013) 18-6.5-108. Mandatory reports of abuse and exploitation of at-rtsk eJders- list of reporters - penalties (1) (a) On and after Jury 1, 2014, a person specified in paragraph (b) of this subsection (1) who observes the abuse or exploitation of an at-risk elder, or who has reasonable cause to believe that an at-risk elder has been abused or has been exploited or is at imminent risk of abuse or exploitation, shall report such fact to a law enforcement agency not more than twenty-four hours after making the observation or discovery. (b) The following persons, whether paid or unpaid, shall report as required by paragraph (a) of this subsection (1): (I) Physicians, surgeons, physicians' assistants, osteopaths, physicians in training, podiatrists, occupational therapists, and physical therapists: (II) Medical examiners and coroners; (III) Registered nurses, licensed practical nurses, and nurse practitioners; (IV) Emergency medical service providers; (V) Hospital and long-term care facility personnel engaged in the admission, care, or treatment of patients; (VI) Chiropractors; (VII) Psychologists and other mental health professionals (VIII) Social work practitioners; (IX) Clergy members; except that the reporting requirement described in paragraph (a) of this subsection (1) shall not apply to a person who acquires reasonable cause to believe that an at-risk elder has been mistreated or has been exploited or is at imminent risk of mistreatment or exploitation during a communication about which the person may not be examined as a witness pursuant to section 13-90-107 (1) (c), C.R.S., unless the person also acquires such reasonable cause from a source other than such a communication; (X) Dentists; (XI) Law enforcement officials and personnel; (XII) Court-appointed guardians and conservators; (XIII) Fire protection personnel; (XIV) Pharmacists; (XV) Community-centered board staff; (XVI) Personnel of banks, savings and loan associations, credit unions, and other lending or 
financial institutions; (XVII) A caretaker, staff member, employee, or consultant for a licensed or certified care facility, agency, home, or governing board, including but not limited to home health 
providers; and (XVIII) A caretaker, staff member, employee of, or a consultant for or of, a home care placement agency I as defined in section 25-27 .. 5-102 (5), C.R.5. (e) A person who willfully violates paragraph (a) of this subsection (l) commits a class 3 misdemeanor and shall be punished in accordance with section 18-1.3-501. (d) Not withstanding the provisions of paragraph {a) of this subsection (1), a person described in paragraph (b) of this subsection (1) is not required to report the abuse or exploitation of an at-risk elder if the person knows that another person has already reported to a law enforcement agency the same abuse or exploitation that would have been the basis of the person's own report. (2) (a) A law enforcement agency that receives a report of abuse or exploitation of an at- risk elder shall acquire, to the extent possible, the following information from the person making the report: (I) The name, age, address, and contact information of the at-risk elder; (II) The name, age, address, and contact information of the person making the report; (III) The name, age, address, and contact information of the at-risk elder's caretaker, if any; (IV) The name of the alleged perpetrator; (V) The nature and extent of the at-risk elder's injury, whether physical or financial, if any; (VI) The nature and extent of the condition that required the report to be made; and (VII) Any other pertinent information.(b) Not more than twenty-four hours after receiving a report of abuse or exploitation of an at-risk elder, a law enforcement agency shall provide a notification of the report to the county department of the at-risk elder's residence and the district attorney's office of the location where the abuse or exploitation occurred. (c) The law enforcement agency shall complete a criminal investigation when appropriate. The Law enforcement agency shall provide a summary report of the investigation to the county department of the at-risk elder's residence and to the district attorney's office of the location where the abuse or exploitation occurred. (3) A person, including but not limited to a person specified in paragraph (b} of subsection (1) of this section, who reports abuse or exploitation of an at-risk elder to a law enforcement agency pursuant to subsection (1) of this section is immune from suit and liability for damages in any civil action or criminal prosecution if the report was made in good faith; except that such a person is not immune jf he or she is the alleged perpetrator of the abuse or exploitation. (4) A person, including but not limited to a person specified in paragraph (b) of subsection (1) of this section, who knowingly makes a false report of abuse or exploitation of an at-risk elder to a law enforcement agency commits a class 3 misdemeanor and shall be punished as provided in section 18-1.3-501 and shall be Liable for damages proximately caused thereby. (5) The reporting duty described in subsection (l) of this section shall not be interpreted as creating a civil duty of care or establishing a civil standard of care that is owed to an at-risk elder by a person specified in paragraph (b) of this subsection (1) of this section. Some exceptions to confidentiality are MANDITORY (i.e. required by law), and others are “permitted”. I can’t predict with accuracy whether any of these exceptions will apply to you or not.  I will attempt to identify these with you should such a situation arise in the process of therapy. Some of these exceptions are part of Colorado law (see section 12-43-218. C.R.S. (1988), in particular). This section does not apply to “covered entities”, their business associates, or health oversight agencies, as each is defined in the “Health Insurance Portability and Accountability Act of 1996”, as amended by the federal “Health Information Technology for Economic and Clinical Health Act”, and the respective implementing regulations. Other exceptions are noted in the Notice Of Privacy Rights found later in this document. You should be aware that except in the case of information given to a licensed psychologist, legal confidentiality does not apply in a criminal or delinquency proceeding, or possibly with regard to an at risk adult (e.g., elderly, disabled). There are other exceptions that I will identify to you if the situation(s) arise during therapy. In general, confidentiality can be broken if you are a danger to yourself, or others, or are incapable of taking care of your self (i.e., unsafe), or if you appear to be in the midst of a medical emergency. Also, I am required to report child abuse and neglect. If you are a minor, and I feel you are engaging in high risk behavior, I may inform you parents or custodian. If you are a minor, it is possible that your parents/custodian(s) could get information from your record. There may be laws that come to be where reporting of adult abuse could also be mandatory. Although Privileged Communication does exist in Colorado, there are certain circumstances where a judge can over rule this and require confidential information to be provided. In general, it is probably a good idea to assume that if any court or legal process is involved, that confidentiality, or privilege is NOT guaranteed. In other words, potentially, all of your records with me are potentially “discoverable“, especially if mental health is identified as an issue in the legal proceedings. Confidentiality might be broken in the process of any law suit, or if a search warrant is issued that involves your information, or if providing information is permitted or required by law. Certain information will be provided to third party payers (e.g., insurance companies, employee assistance programs, etc.) for billing purposes. Also, third party payers may audit some files, and could audit your file and have access to information from your file. If we do couples counseling I will not guarantee to keep “secrets” you have disclosed from your counseling partner.  If you have any questions or doubts about confidentiality, please ask me now. Confidentiality may also be broken in the case of any filing with a licensing or regulatory board, organization, or agency, or if a malpractice lawsuit is filed. If you are under 18 years of age, a personal representative, legal guardian, and/or parent may get information under some circumstances. I will minimize the amount and type of information provided when possible is this occurs. If you feel this could be an issue, please tell me about this, or if in doubt about it, ask me. I hereby acknowledge that I have received a copy of Mark Rush’s Notice of Privacy Rights.
I have read the preceding information, and it has been provided verbally, and I understand my rights as a client/patient.
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Client Signature Date
In general, if you are unhappy, uncomfortable, displeased, upset, disappointed, or unsatisfied with any part of our therapy process, billing or anything else, please bring these issues if there are any to my attention so we can discuss it and deal with it in a constructive and helpful way. 
If at any time you are in treatment with me and you feel you have a life and death emergency, please take care of yourself and immediately call 911 or go to the nearest emergency room, which ever seems most appropriate. Please let me know if you feel that I have crossed any ethnic, cultural, or spiritual/religious “boundaries” in our process of therapy. Some Basic Informed Consent Information: Psychotherapy is not guaranteed to “make you better” or to “work”. We will be working toward your goals, and the purpose is for you to accomplish what you wish to gain from therapy, but these are not guarantees. Also, when discussing, or dealing with psychological, mental, behavioral, emotional, and memory material, you might experience some sense of distress. Please let me know about this so we can discuss it and deal with it. Basically, this psychotherapy is for you, and about your goals, and you are in control in that you are not required to do anything in therapy against your will. You may choose to engage in processes that are uncomfortable for you in order to achieve gains in therapy. However, you can choose to let me know that you do not want to engage in a process that I may suggest. I reserve the right to not engage in a therapeutic process with you that you have requested if in my professional opinion it would be harmful for you. It is important to remember that the therapeutic relationship is a professional relationship designed to help you, and it has limits. The relationship is designed to be helpful to you, and cooperative, and collaborative, and “friendly“. But, we are not “friends“. For example, I am not allowed to accept gifts from you, give you rides in my car, etc . If I refer you to another professional, it would be only for the purposes of advancing your therapeutic work (e.g., another therapist, or psychiatrist, etc.). If it seems appropriate I might recommend that you see a physician for physical medical issues that may be impacting you, including regarding your mental, psychological or emotional state. The fact that I do an initial assessment with you is not a guarantee that I will accept you as a client. If you attend therapy sessions, participate in treatment planning and feedback with me, and indicate that you are attempting to do therapy, I will presume that you are engaged in informed consent for therapy. In rare instances therapy has been associated with negative effects. Other alternatives to therapy exist to deal with psychological, emotional, and behavioral issues. I can not state definitively that you will be worse off if you do not do therapy. Therapy can be terminated by me for legitimate reasons (e.g., missing a lot of appointments, you stop attending appointments, you do not respond to outreach (e.g., phone messages, emails, letters etc.), you do not pay for services, you do not take responsibility for working on goals established, it becomes my opinion that our therapy together is not helping you, or if you or someone connected with you endangers or threatens me). In general, I prefer to use cognitive-behavioral, solution focused, psychoeducational, and strength based approaches. If we decide to use EMD/R, you should know that it may still be considered to be an experimental technique. Techniques that involve visualization or guided imagery could lead to retrieval of a repressed memory. I tend to focus on helping people learn to consciously, and effectively utilize their thinking, emotions, and behavior in a coordinated or integrated way. We will develop therapeutic goals, and will try to stay “on target” with regard to your priorities for treatment. I will also want the approaches or methods we use to make sense to you, and will ask you to discuss, question, etc., if the approach being used does not make sense to you. I also tend to focus on you having something related to your goals to work on in between sessions. I also take into consideration environmental, physiological, and developmental factors. The first or intake session is typically one hour and fifteen minutes long. “Regular” sessions are typically 50 minutes long. I do make notes during an intake, and make notes about each session. My main focus with these is to provide clinical information for myself to track what we are doing, and for other professionals should they be in a position to use this clinical information at some point. A third party payer may limit the number of sessions they will pay for, or the type of issue that they pay for. For example, your insurance may not pay for couples counseling. If you participate in group therapy, it is necessary for you to agree to protect and respect the privacy of other group members. You need to agree not to share personal information, including the names of other group members with people outside of group. Please let me know if you believe another group member has violated this privacy. Payment for services is expected per session unless otherwise arranged. Nonpayment for services could result in termination of services and referral elsewhere (e.g., local mental health center). If I do not respond to you when you have left me a message either on voice mail, or via email, or any other communication method, within what you consider a reasonable period of time, please do not assume I actually got your message, and please contact me again. If we were to incidentally meet in public, I will act as if I do not know you (to protect confidentiality) unless you initiate contact with me. If I am taking a vacation or will be unavailable for a set period of time, I will try to let you know in person, and this information will be available on my voice mail along with the phone number and name of a colleague that you can contact if necessary. If in my professional opinion (either initially or during the course of treatment) I feel that treating you is outside my area of competence, or that you would be better served by a referral, that referral will take place. No-showing for appointments can be a reason for termination of therapy, and a referral elsewhere. If I contact you after a no show, or cancellation, or when we have no future appointment scheduled, and you do not respond to my outreach, I may assume that you have terminated therapy. If you have any questions or would like additional information, please feel free to ask. If you feel you are not making adequate progress, or for some reason feel that another therapist could be more beneficial to you, let me know and I will offer to refer you to another mental health professional. I am not an expert witness. I have expertise a psychologist who does psychotherapy, but not in forensics. It is considered an ethical violation for a psychologist to “act” outside of his/her “scope of practice”. Also, acting in a “dual role” with a client can be considered an ethical violation. Therefore, as you psychotherapist, my focus is to help you obtain your therapeutic goals, and to be involved in a professional role with regard to legal/court related goals you might or might not have in addition to my role as your therapist could constitute an unethical multiple role relationship. Forensic and therapeutic roles are generally considered to be incompatible. For example, I would not have an opinion in a court related process about, what is in the best interest of children, disability, work performance, etc. It also states in the DSM, that it is inappropriate to infer specific functioning from a diagnostic label. 
Effective 11/25/2013 NOTICE OF INFORMATION PRACTICES, PRIVACY RIGHTS, AND FEDERAL REQUIREMENTS REGARDING CLIENT RECORDS (HIPPA): Effective 4-14-03. (privacy notice, administrative, policies and procedures, permitted uses and disclosures of protected health information, uses and disclosures with authorization). This notice describes how medical information about you may be disclosed and how you can get access to this information. Please review it carefully. In general, it is possible that protected health information concerning you could be released with it being as accurate as possible and known, in good faith, for a legitimate purpose designed to be helpful, and allowing you to provide information for proper treatment and evaluation with regard to other professionals (including health care organizations and entities, government officials, business associates for the provision of health care services). In general, release of information, even with a signed release, is limited to the minimum necessary by my best clinical and legal judgment and counsel. There are some restrictions on what information can be used. In general, is usual and customary practice when billing a third party to provide some information, and this may include a diagnosis, date of service, and the type of service, and in some cases other information. This document represents part of the HIPPA documentation required. This notice describes how medical information (including the information gathered in our therapy or treatment) about you may be used and disclosed, and how you can get access to this information (about you). Please review it carefully. It is possible that information could be released in a legal or court process where mental health is at issue. Records could be discoverable in a legal process, or with a court order. Information about you and your health is personal. Thus, Federal and State guidelines will be followed to maintain the confidentiality of your health information. Your information is safeguarded via administrative, physical, and technical means. “Health” information refers to information that identifies you and relates to your medical and/or behavioral health history, care, or payments made for that care. Federal law and regulations are such that your health information can not be released unless you consent in writing, the disclosure is allowed by a court order, or the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit (including a payer source i.e., insurance or managed care company), or treatment evaluation. Violation of Federal law and regulation is a crime. Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or Local authorities. (See 42 U.S.C. 290dd-3 and 42 U.S.C.  290ee-3 or Federal laws and 42 CFR pt. 2 for Federal regulations.) I as your provider am required to abide by the terms of this notice. Your information is used for normal (e.g., routine) business activities that by Federal law fall into the categories of treatment, payment, and health care operations. Below are some examples of how your health information could be used and disclosed relative to these aforementioned categories (although not every such use or disclosure is listed here). Please note that I might be required to, or choose to limit the condition of the release of certain information about you for the purposes mentioned above and listed below. For example, I would not disclose psychotherapy notes or information about your treatment for substance use without getting your specific consent. Treatment: Treatment refers to the provision, coordination, or management of health care (including mental health care) and related services by one or more health care providers. I keep a record of telephone consultations and appointments. This record might include your diagnoses (if any), medications, and your response to medications and other therapies. For example, if you were referred to a psychiatrist regarding depression, the psychiatrist might wish to know your symptom history in this regard. Your health information might also be disclosed in the context of coordinating your care with other providers (e.g., psychiatrists, nurses, other therapists, substance abuse counselors, etc.). (Remember, in order for this information to be released you would have to provide your written consent.) Health Care Operations: Health information is used in order to improve the services I provide. For example, a third party payer may review some of your health information in order evaluate my performance: I may also contact you to remind you of appointments or to tell you about treatments and other services that might be of benefit to you. This means that information could be left via a phone message or a letter to you. If you have specific instructions for me about how or how not to leave messages for you, please let me know. Other Uses and Disclosures: I may also use information to: Recommend treatment alternatives. Tell you about health related products and services. Communicate with other treatment or payer organizations. To help entities that assist me in providing services where they agree to safeguard your information. Comply with Federal, State or Local laws that may require disclosure. Attempt to avert a serious threat to health or safety.  Assist in public health activities such as tracking diseases or medical devices. Inform workers’ compensation carriers and/or your plan if your are injured at work and are making a claim for workers’ compensation. Inform authorities to protect victims of abuse or neglect, or crime information. Inform authorities if you are a victim of abuse, neglect or domestic violence if I believe disclosure is necessary and either you agree to the disclosure or we are required by law to make the disclosure. Comply with Federal and State health oversight activities such as fraud investigations. To plan sponsors as specific in plan documents. Respond to law enforcement officials or to judicial orders, subpoenas or other process. Assist in specialized government functions such as national security, intelligence, and protective services. Conduct research following strict internal review to ensure to ensure the balancing of privacy and research needs. I may be required to release information without your consent for health oversight activities where required by law, when required to report certain communicable diseases or certain injuries, when a Coroner is investigating a death, if a crime is committed against me or observed by me on by business premises, and business associates who have agreed to maintain the privacy of health information (e.g., quality assurance, billing, legal counsel, auditing). If you are treated involuntarily information can be shared pursuant to law with other treatment providers and legal entities as necessary to provide the appropriate care. Except for certain minors, incompetent clients, or involuntary clients, protected health information cannot be provided to family members without the client’s consent. In situations where family members are present during a discussion with the client, and it can be reasonably inferred from the circumstances that the client does not object, information may be disclosed in the course of that discussion. However, if you (the client) object, protected health information will not be disclosed. Again, in life threatening emergencies information may be disclosed in order to avoid serious harm or death.  All other uses and disclosures, in categories not previously described, may only be done with your written permission. Should such permission be obtained from you, you may revoke it at any time, but I am unable to take back disclosures made in reliance on your permission. My Responsibilities: To maintain the privacy of your health information in accordance with Federal and State rules. To provide this notice of my duties and privacy practices. To abide by the terms of the notice currently in effect. I reserve the right to change privacy practices, and make the new practices effective for all the information I maintain. Revised notices will be made available. Your Federal  Rights: The law entitles you to; - Inspect and copy certain portions of your health information. This request must be made in writing, and fees may apply for copying. This does not include psychotherapy notes, and I may deny your request under limited circumstances. - Request amendment of your health information if you feel that it is incorrect or incomplete. This request must be made in writing. If I deny your request, you can file a statement of disagreement. I am not required to amend the record if it is determined that it is accurate and complete. - Receive and accounting of certain disclosures of your health information made after 4-14-03, although this excludes certain disclosures including those made for treatment, payment, and healthcare operations. These requests must be made in writing, and fees may apply. - Request that I restrict how I use or disclose your health information. This request must be made in writing. (I may not be able to comply with all requests.) - Request that I communicate with you in a certain way or at a specific address. This request must be made in writing. This usually done if a client is concerned that confidential information may be accessed by others unless special provisions are made (e.g., sending mail to a different address, or not leaving messages on a home phone, etc.). - Obtain a paper copy of this notice even if you receive it electronically. I ask client before the 1st appointment to either contact their 3rd party payer (ins co, EAP, etc.) or my billing service to get an authorization for payment in place. If this is not done, and the 3rd party payer doesn’t pay for our 1st session, you are responsible for paying for that session yourself. There may be limits on the number of sessions or the amount that your 3rd party payer will pay for therapy. You may have a deductible and/or co-payment that you may be responsible for. You are responsible for paying for sessions that your 3rd party payer doesn’t pay for. If you have questions concerning any of this, please discuss with me. 
What if you have a complaint?
If you believe that your privacy has been violated, you may file a complaint with your third party payer, or with the Secretary of Health and Human Services in Washington, D.C. I will not retaliate or penalize you for filing a complaint (45 C.F.R. 164.520(6)(1)(vi). To file a complaint with the Secretary of Health and Human Services, write to:
Office of Civil Rights
U.S. Department of Health and Human Services
999 18th St., Suite 417
Denver, CO 80202 or call 1-877-696-6775.
This notice applies to health care professionals and to me as a health care provider. If you want more information, please ask me. 
Client Statement: I have read and understand the above, and have received a copy of this Mandatory Disclosure, and a copy of the Notice of Information Practices (which includes Federal confidentiality rules, notice of your privacy rights, copy of your rights as a client, and the complaint process), and I hold that I am competent to understand this material and can knowingly sign this document with awareness.
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Signature of Client or Parent/Legal Guardian (if client is under age 15)      Date
If you think of any questions after having read this please write them below and address them with me.
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BASIC INFORMATION

NAME:_______________________________________________________________________

ADDRESS:____________________________________________________________________
       
______________________________________________________________________________
CITY                     STATE                                         ZIP CODE

HOME PHONE:________________________________________________________________

WORK PHONE: _______________________________________________________________

Preferred Message Method: This means you are giving me permission to leave messages for you this way. (email, voicemail, text):___________________________________________________

BIRTHDATE:_______________________

BIRTHDATE:_______________________   _________________________________________
For Couples Name

IN CASE OF EMERGENCY CALL:________________________________________________
        Name/ Phone/ Relationship/Phone

EMPLOYER ___________________________________________________________________
AFTER HOURS COVERAGE: Call me at 303-949-6297 and I will either answer the phone, or get back to you. I regularly check my voice-mail during working hours. The phone is on overnight. If you don’t hear back from me, don’t assume I got your message as messages are lost sometimes in voice-mail systems. Leave me another message. If you have an imminent (immediate) life and death emergency, call 911 or go to the nearest emergency room. If you don’t want mail, bills, communication to you in a certain way (phone, voice-mail, email, text, fax, conventional mail, etc.) let me know. It is your responsibility to consider the practical limitations of confidentiality inherent in communication technologies. According to standards of practice, I’m not allowed to receive gifts from clients. If you’re not sure about the financial costs of what you’re responsible for paying for therapy, please ask me so we can clarify. At this time my bank charges me $20.00/returned check. If one of your checks is returned you are responsible for reimbursing me for that fee, and for reissuing a valid check or payment. If you are using a third party payer (e.g., EAP, Insurance, etc.) please be clear on the number of  sessions authorized. If you are not sure, please clarify with me. This way we can discuss options for continuation of therapy after allotted sessions are used. No-show Policy: If you don't cancel an appointment you have scheduled at least 24 hours in advance of the scheduled appointment, you owe a $70.00 no show fee. If you have any reason at all for this happening and communicate this to me I will happily waive the fee. This policy is mainly concerning the fact that often someone is wanting a sooner appointment than they have, and if you know you won't be able to keep your appointment and let me know, I can then provide someone with a sooner appointment. You will not receive a formal bill, but you may receive a note reminder you of this policy. If for any reason at all you are not happy with receiving the reminder or anything else concerning this no-show policy, please discuss it with me. Thank you. 

_______________________________________________________________            _________
Signature of client or responsible party                                     Date
___________________________________________________________________________________________________________________________________________________________________________________________

Authorization for Use and Disclosure of Protected Health Information
___ RELEASE/REQUEST OF CONFIDENTIAL INFORMATION FOR TREATMENT, PAYMENT, AND OPERATIONS (This is often used to authorize information required for billing to be sent to third party payers, and/or for coordination with other providers.)
___ AUTHORIZATION for other purposes. If this line is checked, this form is a HIPAA compliant Authorization. As such, Mark Rush may not condition treatment, payment, enrollment or eligibility for benefits on your signing this Authorization.
NAME:__________________________________________________ DATE OF BIRTH:_____________

_____________________________________________________________________________________
Client Address and Phone
I authorize Mark Rush to disclose the following medical records or other protected health information regarding the individual identified above and/or to request information from with the following person or entity: 
NAME ADDRESS
________________________________   ___________________________   Phone_______________
  ___________________________   FAX________________
  ___________________________
Specific Information To Be Released: The execution of this form does no authorize the release of information other than that specifically checked below. There is potential for the information released to be disclosed by the recipient and it may no longer be protected by HIPAA Privacy Regulation. In signing this document you state that you understand that 
___ Diagnosis   ___ Summary of Treatment   ___ Recommendations   ___Length of Treatment
___ Psychological Testing/Evaluation   ___Drug and/or Alcohol Treatment Information
___ HIV/AIDS Status   ___ Written Report   ___ Information by Phone, email, fax, or regular mail.
___Other (specified) __ Mental health condition and treatment information (specified) ________________
The information to be used is limited to the following date(s) or date range of treatment. DATES COVERED: ___________________ ___ All Admissions ___ Most Recent Admission. The above information may be provided at the request of the individual for the following purpose(s):
_____________________________________________________________________________________
Client Statement: I understand that if I have authorized the release of drug and/or alcohol information the Federal Law (42 CFR, Pt. 2) protects the confidentiality of this information. I understand that if I have authorized the release of HIV/AIDS status this information is protected from unauthorized disclosure as provided by Colorado Law (CRS 18-4-412). The information being requested to be used or disclosed my include information relating to Human Immunodeficiency Virus (HIV), sexually transmitted diseases, other communicable diseases, mental health conditions, or drug and alcohol abuse. Information used or disclosed pursuant to this Authorization may be re-disclosed by the recipient and no longer subject to HIPAA. You have a right to receive a copy of this Authorization.
Recipient: If you have received information via this release, this information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR pt. 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR pt. 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
This release of confidential information is being made in compliance with the Privacy Act of 1974 (Public Law 93-579), Freedom of Information Act of 1974 (Public Law 93-502), Federal Rule of Evidence 1158 (Inspection of Copying of Records upon Patient’s Written Authorization), This authorization serves as both a general and specific authorization to release information under the Drug Abuse Office and Treatment Act of 1972 (Public Law 92-255), and the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act Amendments of 1974 (Public Law 93-282), the Veterans Omnibus Health Care Act of 1976 (Public Law 94-581), and the Veterans Benefit and Services Act of 1988 (Public Law 100-322), and in compliance with 42 C.F.R. Part 2 (Public Law 93-282), which prohibits further disclosure without the express written consent of the person to whom it pertains, or as otherwise permitted by such regulations. I understand that if the person or organization that receives this information is not a health care provider or health insurer the information may no longer be protected by federal privacy regulations. 
Client Statement: I certify that this request has been made voluntarily. I understand that I may revoke this release/authorization at any time by written notice to Mark Rush, except to the extent that action has already been taken to comply with it. Without my written revocation, this release/authorization will expire ONE YEAR from the most recent date signed. I hereby release the above parties from liability that may result from furnishing information. A copy of this release/authorization may be utilized with the same effectiveness as an original. I choose for this release to expire on ___________________ (date).
Charges may apply for copies: $14.00 for up to 10 pages, $.50 per page for pages 11-40, and $.33 for each additional page beyond 40.

___________________________________________________________                   ____________
Signature of Client, Parent/Guardian (for client under 15 years of age) Date

________________________________________   ___________________________________________
Signature and date to extend request            Signature and date to extend request
__________________________________________________________________________________________________________________________________________________________________________________________

FAX TRANSMISSION COVER SHEET

DATE:

TO:

FROM:

SUBJECT:

FAX#:

NUMBER OF PAGES INCLUDING COVER SHEET:

NOTE: The information contained in this FAX, including the cover page, is confidential and therefore protected by law. This transmission is covered by the Electronic Communication Privacy Act, 18 U.S.C. @ 2510 et seq. The information contained within, and any documents accompanying this message, are LEGALLY PROTECTED under Federal CLIENT PRIVILEGE LAW. The information contained in this FAX is intended only for the confidential use of the recipient(s) specified on the cover page of this FAX. If you are not the named recipient(s), you are hereby notified that you have received these documents in error, and that review of, reading of, dissemination of, or copying of  this communication is prohibited. If you have received this communication in error, PLEASE notify us immediately by telephone (303-949-6297), and return the FAX including cover page to us by mail. THANK YOU!

MESSAGE:
__________________________________________________________________________________________________________________________________________________________________________________________
SPECIFIC CONSENT FOR PARTICULAR PSYCHOTHERAPEUTIC PROCEDURES:

If I recommend, and you consent to certain therapeutic procedures that involve exposure with response prevention (e.g., EMD/R, Implosion, In Vivo situations), you should be aware that you might become aware of previously repressed difficult or traumatic type memories, and some discomfort or even problems in functioning could arise. Of course, the goal is the opposite. The goals would involve letting memories fade or be less problematic, to over come fear reactions such that you are not overly limited by fear and anxiety in your life. However, you could experience symptoms in association with these kinds of process (e.g., nightmares, intrusive memories at other times, problems sleeping, problems concentrating, depressive symptoms, anger, etc.) If any of this occurs let me know so we can deal with it. You are in control of these processes, in that you can decide not to do them anytime you want to. Even relaxation techniques, meditation, mindfulness techniques can be associated with unexpected and unpleasant memories arising. 
If we decide to use EMD/R, you should know that it may still be considered to be an experimental technique. Techniques that involve visualization or guided imagery could lead to retrieval of a repressed memory.

By signing this statement, you are attesting that we have discussed the procedure or procedures being used that fit the above descriptions, and that any questions you may have had have been answered to your satisfaction, and that you have agreed or consented to going forward with these techniques. 


______________________________________________   _________________
    Client Signature                                                                    Date

__________________________________________________
    Printed Client Name
________________________________________________________________________________________________________________________________________________________________________________________
Mark Rush, Ph.D. 303-949-6297 markrush@markrushphd.com: 4770 E. Iliff Ave. #108 Denver, CO 80222: fax 303-736-4419: www.markrushpd.com
MINOR INFORMED CONSENT DOCUMENT
At age 15 a person in Colorado can sign informed fur their own informed consent for 
psychotherapy, provided they seem to be able to understand the consent in a competent 
manor. As such, the general provisions that exists for majority adults apply to adolescents 
along with the limits on confidentiality that also exist tor majority adults. Refer to the 
mandatory disclosure document you have received. 
However, a minor may have even more exceptions with regard to confidentiality. In 
general, parents of minors are often "entitled" to provide permission as they have some 
legal responsibility for their children. In general, in the absence of known abuse and or 
neglect on the part of parents, they are assumed to have the best interest of their children 
in mind. "Best interests" are often subjective and hard to define in objective ways. It can 
also be difficult to assess the decision making capability of a minor. 
If you use your parent's insurance, or they are paying for your therapy. technically, you 
are not considered the "sole client", and therefore, they may have some access to 
information around your therapy. 
Please discuss with me any issues or questions you have about your confidentiality. 
Thanks. 
Please sign here indicating that you have read and understand the above. If you have any 
questions about this at any time please bring them up sooner rather than later. 
_________________________________________________      ______________
                Client Signature Date
__________________________________________ ___________________________________________________

Client Name Client Name (for couples)
(Clients receive a copy of their treatment plans, if you do not have a copy let me know, so I can give you one.)
TREATMENT PLAN
GOALS AND OBJECTIVES: approximate time frames
PLANS AND METHODS TO ACHIEVE GOALS AND OBJECTIVES:
SOME CLIENT RESPONSIBILITIES: 
Please discuss with me if you feel that the therapy process is off target, techniques are not clear, or you are having trouble using methods we discuss. In this way we can refine and enhance the therapy process in an effort to increase the benefit you can get from therapy.
Truthfulness and forthrightness on the part of the client will likely enhance the probability of favorable outcomes in therapy.
Putting forth genuine effort regarding the goals/objectives and treatment plan will likely enhance the probability of favorable outcomes in therapy.
An unwillingness on the part of the client to do the above can be reason for termination of therapy and/or possible referral to another provider. 

___________________________________________ _________________
 Client Signature Date
Treatment Notes: ____________________________________________________
Client Name(s)
________________________________________________________________________________
TREATMENT NOTES
Notes related to goals/objective and treatment plan (and the process)
Date:
Dx
Sxs
does it seem to be helping
what did you take with you from last session
on target with your therapy priorities?
do the methods make sense
what have you been working on or have changed
what do you want to focus on today
insights from this session? 
refer to tx plan re what discussed today
interventions, techniques, approaches
homework
next appt?:
SI/HI/GD issues if any?
Comments