Janice Lindsay-Hartz, Ph.D., P.A.
Licensed Clinical Psychologist
Licensed Marriage and Family Therapist
Miami, Florida
Page 2

In most situations, I can only release information about your treatment to others if you
sign a written Authorization form that meets certain legal requirements imposed by
HIPAA. There are other situations that require only that you provide written, advance
consent. Your signature on this Agreement provides consent for those activities, as

•        I may occasionally find it helpful to consult other health and mental health
professionals about a case. During a consultation, I make every effort to avoid
revealing the identity of my patient. The other professionals are also legally bound to
keep the information confidential. If you do not object, I will not tell you about these
consultations unless I feel that it is important to our work together. I will note all
consultations in your Clinical Record (which is called “PHI” in my Notice of
Psychologist’s Policies and Practices to Protect the Privacy of Your Health

•        As required by HIPAA, I have a formal business associate contract with my
accountant. The only possible information my accountant would gain access to would
arise if your name were on a check which I wrote.  In my accountant's contract, he
promises to maintain the confidentiality of this data except as specifically allowed in
the contract or otherwise required by law. If you wish, upon your request, I can provide
you with the name of this organization and/or a blank copy of this contract.  I can also
develop a contract with collection agencies, attorneys or other professionals for the
purpose of handling billing disputes.  I may develop a contract with a billing service. If
you wish, upon your request, I can provide you with the name of such organizations or
professionals and/or a blank copy of these contracts should I develop them.  

•        Disclosures required by health insurers or to collect overdue fees are discussed
elsewhere in the Insurance Information and Agreement form.

There are some situations where I am permitted or required to disclose information
without either your consent or Authorization:

•        If you are involved in a court proceeding and a request is made for information
concerning your diagnosis and treatment, such information is protected by the
psychologist-patient privilege law. I cannot provide any information without your (or
your legal representative’s) written authorization, or a court order, or if I receive a
subpoena of which you have been properly notified and you have failed to inform me
that you oppose the subpoena.  If you are involved in or contemplating litigation, you
should consult with your attorney to determine whether a court would be likely to
order me to disclose information.  Please be advised that I am committed to providing
services only as your psychotherapist and to protecting the confidentiality of all of
your information, to the extent it is permissible for me to do so.  

•        I may be required to provide information if there is a court ordered subpoena of
your records for custody cases, or if there is a court ordered subpoena of your
records for any court proceeding in which your mental status is in issue.  

•        If a government agency is requesting the information for health oversight
activities, within its appropriate legal authority, I may be required to provide it for

•        If a patient files a complaint or lawsuit against me, I may disclose relevant
information regarding that patient in order to defend myself.

•        If a patient files a worker’s compensation claim, and I am providing necessary
treatment related to that claim, I must, upon appropriate request, submit treatment
reports to the appropriate parties, including the patient’s employer, the insurance
carrier or an authorized qualified rehabilitation provider.

•        If a patient identifies a licensed health care practitioner, who has engaged in a
current or past incident of sexual misconduct, I am required to report this incident to
the Department of Health (the Department responsible for the practitioner's license)
and Board of Psychology.

There are some situations in which I am legally obligated to take actions, which I
believe are necessary to attempt to protect others from harm and I may have to reveal
some information about a patient’s treatment. These situations are unusual in my

        If I know, or have reason to suspect, that a child under 18 is abused, abandoned,
or neglected by a parent, legal custodian, caregiver, or any other person responsible
for the child’s welfare, the law requires that I file a report with the Department of Child
and Family Services. Once such a report is filed, I may be required to provide
additional information.

        If I know or have reasonable cause to suspect, that a vulnerable adult has been
or is being abused, neglected, or exploited, the law requires that I file a report with the
central abuse hotline.  Once such a report is filed, I may be required to provide
additional information.

        If I believe that there is a clear and immediate probability of physical harm to the
patient, to other individuals, or to society, I may be required to disclose information to
take protective action, including communicating the information to the potential victim,
and/or appropriate family member, and/or the police or seeking hospitalization of the
patient.   (Fantasies and thoughts are confidential; planned actions of harm are not.)

If such a situation arises, I will make every effort to fully discuss it with you before
taking any action and I will limit my disclosure to what is necessary.

While this written summary of exceptions to confidentiality should prove helpful in
informing you about potential problems, it is important that we discuss any questions
or concerns that you may have now or in the future. The laws governing confidentiality
can be quite complex, and I am not an attorney. In situations where specific advice is
required, formal legal advice may be needed.

You should be aware that, pursuant to HIPAA, I keep Protected Health Information
about you in two sets of professional records. One set constitutes your Clinical
Record. It may include information about your reasons for seeking therapy, a
description of the ways in which your problem impacts on your life, your diagnosis, the
goals that we set for treatment, limited information about your progress towards
those goals, limited medical and social history, your treatment history, any past
treatment records that I receive from other providers, reports of any professional
consultations, your billing records, and any reports that have been sent to anyone,
including reports to your insurance carrier. I make every effort to keep the information
entered in this Clinical Record to the minimum necessary, attempting to exclude
anything sensitive or too personal.  

Should you desire more privacy, upon your written request, I shall limit the Clinical
Record only to your dates of treatment and the charges, reports of any professional
consultations, and any reports that have been sent to anyone following your signed

Except in unusual circumstances where disclosure would physically endanger you
and/or others, or makes reference to another person (other than a health care
provider) and I believe that access is reasonably likely to cause substantial harm to
such other person, you may examine and/or receive a copy of your Clinical Record, if
you request it in writing. Because these are professional records, they can be
misinterpreted and/or upsetting to untrained readers. For this reason, I recommend
that you initially review them in my presence, or have them forwarded to another
mental health professional so you can discuss the contents. In most circumstances, I
am allowed to charge a copying and preparation fee. I may withhold copies of your
records until payment of the copying and preparation fees has been made. The
exceptions to this policy are contained in the attached Notice Form. If I refuse your
request for access to your Clinical Records, you have a right of review, which I will
discuss with you upon request.

In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use
and are designed to assist me in providing you with the best treatment. Normally,
these notes simply contain a summary of what you have told me, in your words.  While
the contents of Psychotherapy Notes vary from patient to patient, they can include the
contents of our conversations, my analysis of those conversations, and how they
impact on your therapy. They also contain particularly sensitive information that you
may reveal to me that is not required to be included in your Clinical Record. They may
also include information from others provided to me confidentially. These
Psychotherapy Notes are kept separate from your Clinical Record. Your
Psychotherapy Notes are not available to you, and cannot be sent to anyone else,
including insurance companies, without your written, signed Authorization. Insurance
companies cannot require your authorization as a condition of coverage nor penalize
you in any way for your refusal to provide it.  

HIPAA provides you with several new or expanded rights with regard to your Clinical
Records and disclosures of protected health information. These rights include
requesting that I amend your record; requesting restrictions on what information from
your Clinical Records is disclosed to others; requesting an accounting of most
disclosures of protected health information that you have neither consented to nor
authorized; determining the location to which protected information disclosures are
sent; having any complaints you make about my policies and procedures recorded in
your records; and the right to a paper copy of this Agreement and the Insurance
Information and Agreement, the attached Notice form, and my privacy policies and
procedures. I am happy to discuss any of these rights with you.

I am required to keep confidential the communications that occur between your child
and myself.  Psychotherapy can be effective only with confidentiality.  I may, however,
talk with you about my own observations, impressions and recommendations
concerning your child.   

Patients under 18 years of age who are not emancipated and their parents should be
aware that the law may allow parents to examine their child’s treatment records (the
Clinical Record only, not the private Psychotherapy Notes). Children between 13 and
17 may independently consent to (and control access to the records of) diagnosis and
treatment in a crisis situation. Because privacy in psychotherapy is often crucial to
successful progress, particularly with teenagers, and parental involvement is also
essential, it is usually my policy to request an agreement with all minors and their
parents about access to information. This agreement provides that during treatment, I
will provide parents only with general information about the progress of the treatment,
and the patient’s attendance at scheduled sessions. I will also provide parents with an
oral summary of their child’s treatment when it is complete. Any other communication
will require the child’s Authorization, unless I feel that the child is in danger or is a
danger to someone else, in which case, I will notify the parents or appropriate persons
of my concern. Before giving parents any information, I will discuss the matter with the
child, if possible, and do my best to handle any objections he/she may have.    

Should you have any questions or concerns about your child's therapy and how it is
going, it is important that you discuss these with me.  Therapy is more effective when
your child and you feel comfortable with your therapist and feel free to discuss

Bills for therapy will be given to you or mailed to you during the first week of every
month.  Bills are due within one week of receipt.  It is my policy that you are
responsible for the bills and that you pay me directly.    My fees may be raised after
one year.  

If your account has not been paid for more than 60 days and arrangements for
payment have not been agreed upon, I have the option of using legal means to secure
the payment. This may involve hiring a collection agency or going through small claims
court which will require me to disclose otherwise confidential information. In most
collection situations, the only information I release regarding a patient’s treatment is
his/her name, the nature of services provided, and the amount due.

Accounts that are past due over 3 months will be charged interest at a rate of 1% a
month compounded.

In order for us to set realistic treatment goals and priorities, it is important to evaluate
what resources you have available to pay for your treatment. If you have a health
insurance policy, it will usually provide some coverage for mental health treatment.  
However, you also have the option of paying privately, maintaining the strictest
confidentiality of your records, and releasing no information to your insurance

If you wish me to provide requested information to your insurance carrier, I shall have
you sign a separate Insurance Information and Insurance Agreement form, agreeing
that I can provide this information.

Your signature below indicates that you have read the information in this document
and agree to abide by its terms during our professional relationship.   Your signature
also indicates that you consent to treatment, after having been informed of the
benefits and risks.

Signature:  _____________________________________________________

Printed Name:  _____________________________________________

Date: ___________________________________________

Form created: 3/03

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Near S. Dixie
Highway and
S.W. 22nd Ave.
Miami, FL  33133

(305) 662.4127