HIPAA Privacy Authorization and Release Form for Lisa Miller, LCMHC Resident Intern
This form provides a client’s informed authorization for use and disclosure of his/her protected health information, including personally identifiable information. This form is required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164 (HIPAA) to be completed, signed, and dated by the client prior to the use and disclosure of the client’s protected health information, as described below.
This form must be maintained securely by the healthcare provider.
Section I – Authorization
I understand that my counselor, Lisa Miller, is a graduate student in the master’s degree in the Clinical Mental Health Counseling program at Liberty University and that my counselor is providing my counseling session(s) as a required part of her internship requirement for that program.
I authorize Soul Care Christian Counseling Services and Lisa Miller to video record all or part of my counseling session(s) from 8/24/20 to 5/30/21 and to use and disclose the video recording, including my name and all of my protected health information contained in the video recording, to the counselor/student’s practicum, internship, or externship course instructor and students in that course at Liberty University.
Section II – Extent of Authorization
I understand that the purpose of the video recording is for the above-named counselor/student to receive professional training and constructive feedback on his/her counseling skills to improve the quality of counseling services that I (and future clients of the counselor/student) receive. To be specific, once I complete and sign this form, I understand that the above-named counselor/student will upload the video recording of my counseling session(s) to Kaltura and/or WebEx Teams, both of which are password-protected platforms used by Liberty University for educational purposes. The video recording (and a written transcript of the video recording) will be disclosed to and used by the counselor/student’s practicum, internship, or externship course instructor and the students in that course for educational and professional training purposes, including a course presentation, a case conceptualization, and a verbatim paper. I understand that my personally identifiable information (e.g., my name) will be redacted from the written transcript and other written assignments, but not redacted from the video recording. I further understand that neither the video recording nor any written assignment will be used for any other purpose or disclosed to any persons outside of the counselor/student’s course, as described herein, without my additional written consent, except as permitted or required by law (see Section IV below).
Section III – Effective Period
This HIPAA Privacy Authorization and Release Form is valid and remains in effect until the end of the counselor/student’s practicum, internship, or externship course. I understand that the video recording and the written transcript will be deleted at that time. If there is a desire to keep either the video recording or the written transcript for a longer period of time, my additional written consent will be required before doing so.
Section IV – Acknowledgements and Disclosures
I understand that the above-named healthcare provider and counselor/student, as well as the course instructor and students will be required to maintain the same confidentiality as that required by members of the counseling profession. However, I acknowledge that there are certain exceptions to such confidentiality that require disclosure even without my authorization. Such exceptions that may require disclosure include: (1) my threat or act of serious harm to myself or another, (2) my disclosure of abuse of a minor, an elder, or an incapacitated adult, and/or (3) the issuance of a lawful subpoena, search warrant, or judicial court order that requires disclosure.
I understand that I have the right to revoke this authorization, in writing, at any time. I understand that my revocation will not be effective to the extent that any person or entity has already acted on my authorization. In other words, a revocation of my authorization cannot be retroactive and it will become effective only when my written revocation is received and processed. My written revocation of this authorization must be sent to:
Name: __Chantelle Johnson______
Organization: Soul Care Christian Counseling Servics
Address: 5501 Executive Center Dr Suite #215, Charlotte, NC 28212
Email Address: cjohnson@mysoulcare.org
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be subject to or conditioned on whether I sign this authorization. I understand that my decision to sign this form, and therefore to release my protected health information, is completely voluntary.
I understand that, although my information used and disclosed pursuant to this form will be kept confidential and only used as described above, such information may no longer be protected by state or federal law, including HIPAA. Moreover, even though the video recording and the written transcript of my counseling session(s) will be deleted, I understand that written assignments, feedback, reviews, and grades based on them may be education records of the counselor/student that are maintained by Liberty University beyond completion of the course described in Section III above. In such event, my personally identifiable information will not be part of any such education records.
This form must be maintained securely by the healthcare provider.
Section I – Authorization
I understand that my counselor, Lisa Miller, is a graduate student in the master’s degree in the Clinical Mental Health Counseling program at Liberty University and that my counselor is providing my counseling session(s) as a required part of her internship requirement for that program.
I authorize Soul Care Christian Counseling Services and Lisa Miller to video record all or part of my counseling session(s) from 8/24/20 to 5/30/21 and to use and disclose the video recording, including my name and all of my protected health information contained in the video recording, to the counselor/student’s practicum, internship, or externship course instructor and students in that course at Liberty University.
Section II – Extent of Authorization
I understand that the purpose of the video recording is for the above-named counselor/student to receive professional training and constructive feedback on his/her counseling skills to improve the quality of counseling services that I (and future clients of the counselor/student) receive. To be specific, once I complete and sign this form, I understand that the above-named counselor/student will upload the video recording of my counseling session(s) to Kaltura and/or WebEx Teams, both of which are password-protected platforms used by Liberty University for educational purposes. The video recording (and a written transcript of the video recording) will be disclosed to and used by the counselor/student’s practicum, internship, or externship course instructor and the students in that course for educational and professional training purposes, including a course presentation, a case conceptualization, and a verbatim paper. I understand that my personally identifiable information (e.g., my name) will be redacted from the written transcript and other written assignments, but not redacted from the video recording. I further understand that neither the video recording nor any written assignment will be used for any other purpose or disclosed to any persons outside of the counselor/student’s course, as described herein, without my additional written consent, except as permitted or required by law (see Section IV below).
Section III – Effective Period
This HIPAA Privacy Authorization and Release Form is valid and remains in effect until the end of the counselor/student’s practicum, internship, or externship course. I understand that the video recording and the written transcript will be deleted at that time. If there is a desire to keep either the video recording or the written transcript for a longer period of time, my additional written consent will be required before doing so.
Section IV – Acknowledgements and Disclosures
I understand that the above-named healthcare provider and counselor/student, as well as the course instructor and students will be required to maintain the same confidentiality as that required by members of the counseling profession. However, I acknowledge that there are certain exceptions to such confidentiality that require disclosure even without my authorization. Such exceptions that may require disclosure include: (1) my threat or act of serious harm to myself or another, (2) my disclosure of abuse of a minor, an elder, or an incapacitated adult, and/or (3) the issuance of a lawful subpoena, search warrant, or judicial court order that requires disclosure.
I understand that I have the right to revoke this authorization, in writing, at any time. I understand that my revocation will not be effective to the extent that any person or entity has already acted on my authorization. In other words, a revocation of my authorization cannot be retroactive and it will become effective only when my written revocation is received and processed. My written revocation of this authorization must be sent to:
Name: __Chantelle Johnson______
Organization: Soul Care Christian Counseling Servics
Address: 5501 Executive Center Dr Suite #215, Charlotte, NC 28212
Email Address: cjohnson@mysoulcare.org
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be subject to or conditioned on whether I sign this authorization. I understand that my decision to sign this form, and therefore to release my protected health information, is completely voluntary.
I understand that, although my information used and disclosed pursuant to this form will be kept confidential and only used as described above, such information may no longer be protected by state or federal law, including HIPAA. Moreover, even though the video recording and the written transcript of my counseling session(s) will be deleted, I understand that written assignments, feedback, reviews, and grades based on them may be education records of the counselor/student that are maintained by Liberty University beyond completion of the course described in Section III above. In such event, my personally identifiable information will not be part of any such education records.
