Your signature below indicates your consent to abide by these terms of our professional contract. I agree to pay for appointments that are missed when not canceled with a 24-hour notice. CLIENT NOTIFICATION OF PRIVACY RIGHTS The Health Insurance Portability and Accountability Act (HIPAA) has created new patient protections surrounding the use of protected health information. Commonly referred to as the “medical records privacy law”, HIPAA provides patient protections related to the electronic transmission of data (“The transaction rules”, the keeping and use of patient records (“privacy rules”), and storage and access to health care records (“the security rules”). HIPAA applies to all health care providers, including mental health care, and providers and health care agencies throughout the country are now required to provide patients a notification of their privacy rights as it relates to their health care records. You may have already received similar notices such as this one from your other health care providers. Please read this document as it is important you know what patient protections HIPAA affords all of us. In mental health care, confidentiality and privacy are central to the success of the therapeutic relationship and as such, you will find I will do all I can to protect the privacy of your mental health records. If you have any questions about any of the matters discussed in this document, please do not hesitate to ask me further clarification. By law, I am required to secure your signature indicating that you have received this Client Notification of Privacy Rights document. Thank you for your thoughtful consideration of these matters. Tamara Raphaeli, Psy.D., Licensed Clinical Psychologist HSP I understand and have been provided a copy of Dr Raphaeli’s Client Notification of Privacy Rights document which provides a detailed description of the potential uses and disclosures of my protected health information, as well as my rights on these matters. I understand I have the right to review this document before signing this acknowledgment form.