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The Hallowell Center Patient Service Agreement

This page contains important information about our professional services and policies, and about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (P.H.I.). HIPAA requires that the Hallowell Center provide you with a notice of Privacy Practices for use and disclosure of P.H.I. for treatment, payment and health care operations. The law requires that the Hallowell Center obtain your signature acknowledging that we have provided you with this information.

Limits on Confidentiality

The law protects the privacy of all communication between a patient and the patient's treaters. In most situations, the Hallowell Center can only release information about your evaluation/treatment to others if you sign a written authorization 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 follows:

  • Hallowell Center clinicians find it helpful to consult about treatment with each other,
    or with a clinician outside the center. All clinicians are legally bound to keep the
    information discussed confidential.

  • The Hallowell Center employs administrative staff as well as mental health professionals. All staff members have been given training and are contractually bound to protect your privacy and maintain confidentiality.

There are some situations where the Hallowell Center is 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, the Hallowell Center cannot provide any information without you or your legal representative's written authorization or court order.

  • If a patient files Worker's Compensation, the Hallowell Center must, upon appropriate request, provide appropriate information, including a copy of the patient's record to the patient's employer, the insurer, or the Department of Worker's Compensation.

There are situations in which the Hallowell Center is legally obligated to take actions which are necessary to protect others from harm. In such situations, we may need to reveal some private health information about your evaluation/treatment. These situations are very unusual in the Hallowell Center practice.

All information disclosed by persons aged 18 and over during the course of evaluation/ treatment is confidential unless the patient is clearly a danger to himself/herself or a danger to others, or unless an incident is disclosed regarding neglect or abuse of children (under age 18), mentally or physically disabled persons, or to the elderly. We are mandated by state law to report suspected abuse or neglect of children. If such situations arise, we shall make every effort to fully discuss this with you before taking any action and to limit the disclosure to what is necessary.

Professional Records

In your patient record at the Hallowell Center, we keep particular information about you. The record may have your diagnosis, reason for seeking treatment, goals set for treatment, your progress towards those goals, your medical/family/social history, treatment history, and past treatment records. Your record may also contain billing forms, and requests from you allowing specific people to have access to your record (i.e., other care providers, or insurance providers). If you request it in writing, you may examine and/or receive a copy of your record, unless we believe that access to it would endanger you. In those situations, you have the right to a summary of your record, and to have your record sent to another mental health provider or to your attorney.

Patient Rights

HIPAA provides you with rights regarding your Clinical Record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of 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 policies and procedures recorded in your records; and the right to a paper copy of this Agreement. We are happy to discuss any of these rights with you.

Minor and Parents

By law, parents of patients who are under 18 years old and not emancipated are allowed to examine their child's treatment records and hold the rights regarding release of information.

Insurance Information

The Hallowell Center does not contract with any insurance companies. Some Hallowell Center patients seek benefits from their insurance companies on their own. You should be aware that insurance companies often require a clinical diagnosis, treatment plans, treatment summaries, or copies of a patient's entire record. We shall only provide this information if you sign a release form specifying who is to receive the information, type of information to be released, the purpose for which the information is being requested, and for what period of time the authorization is valid.

This agreement is being provided according to the Health Insurance Portability and Accountability Act. We will be happy to provide you with a copy of this agreement if you request one.


Hallowell Center Sudbury • 144 North Road, Suite 2450 • Sudbury, MA 01776 • ph 978-287-0810

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