Counseling Collaborative Privacy Notice

This notice describes how health information about you may be used and disclosed and how you can get access to this information. It is required by the new privacy regulations issued by the U.S. Department of Health and Human Services. Please review it carefully. This notice will become effective on April 1, 2003.

Every time you come in for a session with your Counseling Collaborative therapist a record of that visit is made. This record usually contains information about your symptoms, diagnosis, background and history, treatment and a plan for future care or treatment. Each Counseling Collaborative therapist is responsible for the proper storage of his/her records. Records may be stored on paper or on computer. With your signed consent, your Counseling Collaborative therapist may obtain medical and/or mental health information from other providers or facilities and may discuss your treatment with them. This information is considered "protected health information" and is made part of the record and all information stored in the record is considered private and subject to the protections described in this privacy notice.

With your signed consent, your "protected health information" is used for the following purposes:

  • Collaboration with other care providers, as indicated, regarding your treatment plan.

  • Obtaining consultation from Counseling Collaborative colleagues with particular areas of expertise or from the Counseling Collaborative team during clinical staff meetings to improve the quality and efficacy of your care.

  • To provide any mental health information, such as diagnosis and symptoms, required to process claims and/or obtain reauthorization for continuing care from your insurance company.

Your Rights Regarding Mental Health Information

The health record is the property of the Counseling Collaborative therapist who compiled it, however the information belongs to you. You or your legally recognized guardian or representative have the right to:

  • Obtain a paper copy of this privacy notice upon request.

  • Request a restriction on some uses and disclosures of the information contained in your health record.

  • Inspect and obtain a copy of your health record.

  • Request that your health record be amended.

  • Obtain a list of the providers/facilities who have received a paper copy of all or part of your health record.

  • Revoke your authorization to use or disclose health information except in cases where information has already been released.

  • Request communications of your health record by alternative means or at alternative locations.

The Counseling Collaborative Therapist's Responsibilities

The Counseling Collaborative therapist is required to:

  • Protect the privacy of your health information at all times

  • Provide you with a notice about his/her legal duties and privacy practices in regard to the information he/she collects and keeps about you

  • Abide by the terms of this notice

    Notify you if he/she cannot agree to a requested restriction on the use or disclosure of your health information you have made

  • Notify you if he/she cannot agree to a requested amendment to your health information you have made

Counseling Collaborative has the right to modify its privacy practices. Revisions will be posted and you will be furnished a copy of the revised privacy notice delineating the changes in our privacy practices.

Without exception, we will not use or disclose your health information except as described in this notice.

Examples of Uses of Health Information For Collaboration with Other Providers For the Purposes of Treatment Planning, Obtaining Consultation From Colleagues and To Process Claims and Authorizations to Your Insurance Company

Collaboration with other providers for the purposes of treatment planning

For example: After an initial evaluation, a client begins individual therapy with a Counseling Collaborative therapist recommended by her primary care provider. Her primary care provider is treating her for Diabetes and chronic back pain that developed after an automobile accident, both of which are affecting her mood. She is also seeing a psychiatrist who has prescribed an antidepressant that has begun to take effect in treating her depression. The Counseling Collaborative therapist confers with the PCP and psychiatrist and gets their input on the initial treatment plan developed with the client and makes plans to speak with them periodically, after obtaining the client's signed authorization.

Obtaining consultation on behalf of a client from a Counseling Collaborative colleague or from the Counseling Collaborative team at clinical staff meeting

For example: A woman in individual therapy with a Counseling Collaborative therapist to address parenting issues presents her concerns about her 7 year old son's behavior and wonders whether he might benefit form therapy at this time. Not trained as a child therapist, the Counseling Collaborative therapist offers to speak to one of her Counseling Collaborative colleagues with many years' experience in child treatment and to discuss the results of this consultation with the client during the next session.


For example:  Concerned about a client's repeated failed attempts to quit smoking and control weight gain in spite of serious complicating health issues, a Counseling Collaborative therapist decides to present this clinical situation at the next clinical staff meeting. Specifically, he needs help determining if the client is a candidate for hypnosis and wants the input of two colleagues trained in this specialty. He also wants help from the group in identifying other potential treatment options and resources in the area.

Using health information to process claims and obtain treatment authorizations from insurance companies

For example: If you choose to use the mental health benefit your insurance company provides to you, your Counseling Collaborative therapist must furnish your identifying information, diagnosis, the dates of service and the type of service, such as individual therapy, as required by the insurer to obtain payment.


For example: Your insurance company allows 8 initial mental health visits before authorization is required. You and your Counseling Collaborative therapist agree as the 8th visit approaches that it would be best for you to have at least 6 additional visits. You would like to continue using your mental health benefit. Your therapist informs you he must complete a treatment extension form that includes your identifying information, diagnosis, goals, progress toward goals and symptoms in order to obtain these additional covered visits.

Use Or Disclosure Of Health Information Without Authorization

Counseling Collaborative is allowed by federal or state law or regulation to disclose health information without authorization from the client or legally recognized guardian/representative in the following circumstances:

  • In medical emergency situations protected information can be disclosed to another professional or facility taking care of the client, and as necessary, to a client's family.

  • When a client is being referred to another provider or facility for care.

  • In addition to being entitled to information for the purposes of processing claims and authorizing care, insurance companies have the right to conduct site visits to providers in their networks during which they may review records.

  • The law requires that mental health providers provide information to health oversight agencies if requested to do so.

  • We may disclose health information to the extent authorized by and to the extent necessary to comply with the laws governing workers compensation or other similar programs established by law.

  • As required by law, we may disclose health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

  • We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

  • We may use or disclose information about you to notify a family member, personal representative, or another person responsible for your care, your location and general condition, if indicated.

  • Using our best judgment, we may disclose to a family member, other relative, or any other person you identify, health information relevant to this person's involvement in your care, especially in the case of an emergency.

  • We are permitted to disclose your health information to contracted business associates, which in our case, include our professional medical billing service and our answering service so they can perform their respective jobs of billing you and your third party payer for the services we have rendered and providing a 24-hour emergency phone coverage service. To protect your health information, however, we require each business associate to enter into an agreement requiring that it appropriately safeguards your information.

Your Counseling Collaborative therapist is required to furnish you with a copy of the "Informed Consent Regarding Limitation On Confidential Communications" document. A companion to this privacy notice, that document covers additional specific limitations to confidentiality. Please review it carefully and sign and date it. You will be given the original signed copy for your records.

Use Or Disclosure With Authorization

Disclosures of information from your health record other than those included in this privacy notice will be made upon your written authorization or that of the person legally able to act on your behalf.

For More Information Or To Report A Problem

If you have any questions about this notice or want more information you may contact the Counseling Collaborative Compliance Officer, Michael Mancusi, at 781-861-1818.

If you think your privacy rights have been violated you are encouraged to file a complaint with the Counseling Collaborative Compliance Officer either by phone or in writing.  Written complaints can be mailed to Counseling Collaborative, 57 Bedford Street, Suite 125, Lexington MA 02420, Attention: Compliance Officer or to the Office for Civil Rights, U.S. Department of Health and Human Services, Government Center J.F.Kennedy Federal Building - Room 1875, Boston, MA 02203, voice phone (617) 565-1340, FAX (617) 565-3809, TDD (617) 565-1343. These complaints will be kept confidential.