Living Hope Eating Disorder Treatment Center Privacy Notice
HIPAA Authorization, Patient Terms of Participation, and Privacy Notice

I understand that my treatment records are protected under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). 45 C.F.R. parts 160 & 164 and cannot be disclosed without my written consent unless otherwise provided for by the regulations.

I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows: One year from date of the patient’s signature on this form.

I understand exceptions to this include but are not limited to, in accordance with the Health Insurance and Portability and Accountability Act (HIPAA), the following: Treatment, payment, and health care operations (e.g., quality improvement and credentialing) purposes. C.F.R 164.506(c) To report child abuse or neglect. 45 C.F.R. § 164.512(b)(1)(ii) To a person reasonably able to prevent or lessen a serious and imminent threat to the health or safety of a person, other or the public. (45 C.F.R. § 164.512 (j) To an individual exposed to or at risk of contracting a communicable disease. 45 C.F.R § 164.512(b)(1) (v) To report suspected abuse, neglect, or domestic violence in limited circumstances. 45 C.F.R. § 164.512 “Federal Regulation (42 C.F.R. Part 2) prohibits any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to who it pertains, or as otherwise permitted by such regulations. 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.” Treatment services are not contingent upon or influenced by the patient’s decision to permit the information release. The information authorized for release may include records which may indicate the presence of a communicable or non-communicable disease.