11062b_f0cd2b56e86443d68d21b6bc12fe055c_

ACKNOWLEDGEMENT OF PRIVACY PRACTICE

Luminesce Counseling :: 6018 SE Stark Street, Portland, OR 97215 :: 502.208.2055

I understand that Luminesce Counseling will use and disclose health information about me. I understand that my health information may include information both created and received by the Luminesce Counseling, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.

I understand and agree that Luminesce Counseling. may use and disclose my health information in order to:

  • make decisions about and plan for my care and treatment

  • refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment

  • determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all my health care

  • perform various office, administrative and business functions that support my practitioner/ provider’s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.

 

I also understand that I have the right to receive and review a written description of how Luminesce Counseling will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of Luminesce Counseling and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of Luminesce Counseling’s Notice of Privacy Practices in effect will be posted in the waiting/reception area.

I understand that I have the right to ask that some or all my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that Luminesce Counseling is not required by law to agree to such requests.