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CONFIDENTIALITY OF PATIENT RECORDS
The confidentiality of your records, maintained by Roland Gabbert, LCSW, are protected by Federal Law Regulations.
Generally, this provider will not say to any person outside this office that you
are in therapy or any details of your therapy, unless:
1. You give consent in writing;
2. You present a danger to yourself or other;
3. The disclosure is required by a court order and/or subpoena
4. Your treatment is ordered by or under the supervision of the courts;
5.
The disclosure is made to medical personnel in a medical emergency or
to qualified personnel or research, audit or program evaluation;
6. Your insurance company must verify treatment before paying my charges;
7. There is suspected physical or sexual abuse or neglect of a child or an adult.
(See 42 U.S.C. 29Odd 3 and 42 U.S.C. 29Oee 3 for Federal Laws and 42 CFR Part 2 for Federal Regulations)
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Client"s
Signature
Date
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Witness's
Signature
Date
