The confidentiality of consumer information is protected by both state and federal laws and regulations. The Esposito Institute, Inc. has an obligation to protect your right to privacy and is committed to holding confidential any information that you provide. The Esposito Institute, Inc. cannot acknowledge our professional relationship with you to any person, including your family and friends without your written authorization. Benita Esposito may discuss your situation with other professionals in peer supervision to ensure that you are given the best possible care. However, Benita Esposito will do so only within the guidelines of HIPAA, C.F.R. 42 and Georgia General Statutes. I will not disclose information regarding a client unless authorized to do so by the client in writing.
LIMITS TO CONFIDENTIALITY AND MANDATED REPORTING
While most information shared with a counselor is private and confidential, I (Benita Esposito) will disclose information to other parties under certain circumstances:
- I am required by law to report any suspected instances of child abuse or neglect to the department of social services in your county. Making a report does not necessarily mean that the counselor believes abuse or neglect occurred, only that a reasonable person might suspect it did.
- Similarly, the law requires that I contact authorities in the event that elder abuse is discovered. This means that an adult age 60 or over who cannot make a call themselves is suspected of being abused or neglected.
- If I believe that you are at risk of attempting suicide, the courts have mandated that I notify any parties necessary to ensure your safety, for example, police, emergency services, and family members.
- If I believe that you are at risk of harming or killing someone else, I must warn the intended victim and/or others who can prevent the assault from occurring.
- I am permitted by law to provide limited information to collection agencies in the event that you would refuse to pay a lawful bill for services.
- If I am ordered by a court to testify about you against your wishes, I will make efforts to avoid testifying, e.g., asserting your right to confidential communications, but I may not always be able to do so.
- If you are referred for services by the court or by your employer, they may require that certain information be released back to them. Clarify what is required before sharing personal information with a counselor.
- A counselor may legally and ethically seek professional consultation with another professional about your case. In such a situation, the consultant will be legally required to treat that information as confidential.
The law requires that I obtain your signature acknowledging that I have provided you with this information. By signing this form, you are certifying that you have been offered this notice and given a copy of the notice if you want one. You may revoke this Agreement in writing and that will be binding on the Esposito Institute unless (1) I have taken action in reliance on it or (2) if there are obligations imposed on Esposito Institute, Inc. by your health insurer in order to process or substantiate claims, or (3) if you have not satisfied any financial obligations. Your signature indicates that you have read the preceding information in full, and that you understand the information and agree to abide by its terms during our professional relationship. Please ask for clarification of any information you are unclear about.
The Esposito Institute, Inc. * P O Box 1074, Young Harris, GA 30582