Agape Counseling Services, PLLC
Notice Regarding Patient Records Privacy:
Policies and Procedures
This Notice is effective on April 14, 2003
This notice describes how Psychological and Medical information about you may be
used and disclosed and how you can get access to this information. Please review it
carefully. You will be asked for your signature to acknowledge receipt of this
We are required by law to protect psychological/medical information about you.
We are required by law to protect the privacy of psychological/medical information about
you and that identifies you. This psychological/medical information may be information
about health care we provide to you or payment for health care provided to you. It may
also be information about your past, present, or future medical condition.
We are also required by law to provide you with this Notice of Privacy Practices
explaining our legal duties and privacy practices with respect to psychological/medical
information. We are legally required to follow the terms of this Notice. In other words,
we are only allowed to use and disclose medical information in the manner that we have
described in this Notice.
We may change the terms of this Notice in the future. We reserve the right to make
changes and to make the new notice effective for any or all medical information that we
maintain. We may or may not make change retroactive. If we make changes to the
notice, we will:
• Post the new notice in our waiting area.
• Have copies of the new notice available upon request.
The rest of this notice will:
• Discuss how we may use and disclose medical information about you.
• Explain your rights with respect to medical information about you.
• Describe how and where you may file a privacy-related complaint.
We may use and disclose psychological/medical information about you in several
We use and disclose psychological/medical information a