Hippa Agreement

MEMBER RIGHTS AND RESPONSIBILITIES

17800 Chillicothe Rd., Ste. 230
Chagrin Falls, OH 44023
Office: 440-543-4771
Appointment: 440-666-0995
bob@www.bobschuppel.com

Form available to fill out online or download, print and fill out. Download available bottom of this page.

  • Patient Rights

    • Patients have the right to be treated with dignity and respect
    • All people have access to treatment
    • Patients have the right to have their information about treatment kept private Only in emergency situations or where required by law can records of your treatment be released without patient permission
    • Patients have the right to an understandable explanation of their diagnosis and treatment options
    • Patients have the right to information about the counselor
    • Patients have the right to know the clinical guidelines and techniques used in their treatment
    • Patients have the right to know about the complaint, grievance, and appeal process
    • Patients have the right to share in their treatment planning and process

  • Patient Responsibilities

    • Patients have the responsibility to provide information to the counselor to help guide treatment
    • Patients have the responsibility to inform the counselor when treatment plan is not working
    • Patients have the responsibility to follow their treatment plan (includes pediatrician and psychiatrist if applicable) to inform all providers as to how treatment is unfolding
    • Patients have the responsibility to ask their providers questions about their care
    • Patients have the responsibility to let their providers know about problems paying fees
    • Patients have the responsibility to follow the treatment plan which is agreed upon by patient and provider
  • I have read and understand my Member Rights and Responsibilities
  • Robert Schuppel, M. Ed., LPCC
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