I am aware that what I discuss in treatment will be treated confidentially and in accordance with the law and recognized professional standards. I understand that only I can give up my right to privacy by signing a release. I also understand that the limits of confidentiality do not extend to situations involving child abuse or neglect, situations where your provider or one of their staff members believe that I might harm myself or another person or if a court of law issues a legitimate subpoena.
I understand and agree that this statement of confidentiality extends to my provider and all professional staff responsible for my care. I agree that my provider may do the following, unless I specifically give direction prohibiting such activity; send routine correspondence, such as billing statements and newsletters to the address I have provided and leave messages on an answering machine or voice mail associated with the telephone numbers I have provided to either confirm appointments or to request that I call the practice on medical or billing matters.
I understand and permit my provider and the professional staff to release information to my insurance company necessary to process claims including any written report to the insurance carrier that the insurance company may require for reimbursement. I also understand and agree that my insurance carrier may insist on auditing or inspecting my records.