Client Forms & Privacy Policy
At Blessed Hands Mind & Body Healthcare, we prioritize your privacy and confidentiality with the highest level of care and professional integrity. We are committed to maintaining the security of your medical and treatment records at all times.
Under state and federal law, the relationship between a patient and an Advanced Practice Nurse is strictly protected. With very few legal exceptions, your personal health information will never be shared without your explicit written permission.
Privacy Rights for Adolescents
In accordance with healthcare privacy laws, adolescents aged 14 and older hold the same rights to privacy and confidentiality regarding their mental health and substance use treatment records. For adolescents in this age group, written authorization must be provided before information can be released, including to parents or legal guardians.
Exceptions to Confidentiality
To ensure safety and comply with legal mandates, confidentiality may only be broken without written consent in the following specific circumstances:
- Suspected Abuse or Neglect: If there is suspicion or evidence of child abuse or neglect, dependent adult abuse, or elder abuse, the law requires an immediate report to appropriate protective authorities.
- Harm to Others: If a patient communicates an explicit or serious threat of physical harm toward another individual, law enforcement and the intended victim must be notified to ensure safety.
- Harm to Self: If a patient threatens or intends to inflict serious harm upon themselves, we will make every effort to collaborate on a safety plan. If cooperation is not possible, necessary measures will be taken to protect the patient's life and safety.
Required Intake & HIPAA Forms
Below, you will find our intake documents, confidentiality acknowledgments, and HIPAA Privacy Notices. Please review and complete these forms prior to your initial visit:
- Notice of HIPAA Privacy Practices
- Patient Rights & Confidentiality Agreement
- Adolescent Privacy & Consent Form (Ages 14+)
- Authorization for Release of Medical Records