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Release of Information Authorization Form

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General Statement of Privacy Practices

We at the Relationship Therapy Center value your privacy. By providing your phone number and/or email address, you agree to receive communications from the Relationship Therapy Center regarding your appointments and clinic updates. Your phone number, email address, and other personal information will be kept confidential and will not be shared with or sold to any third parties without your express written consent to release that information. We use industry-standard security measures to protect your data. You may opt out of communications from the Relationship Therapy Center at any time by emailing us at contact@mncouplescounseling.com or calling us at 612-787-2832.

HIPAA Notice of Privacy Practices


  1. Uses and Disclosures for Treatment, Payment, and Health Care Operations

RTC may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your  consent. To help clarify these terms, here are some definitions:

  • PHI” refers to information in your health record that could identify you.  
  • “Treatment, Payment, and Health Care Operations” 
    Treatment is when your therapist provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be when your therapist consults with another health care provider,  such as your family physician or a psychologist.
    Payment is when RTC obtains reimbursement for your healthcare. Examples of payment are when RTC discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
    Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health  care operations are quality assessment and improvement activities, business-related matters, such as audits and  administrative services, and case management and care coordination. 
  • Use” applies only to activities within my [office, clinic, practice group, etc.], such as sharing, employing, applying,  utilizing, examining, and analyzing information that identifies you. 
  • Disclosure” applies to activities outside of the clinic such as releasing, transferring, or providing access to information  about you to other parties.  
  1. Uses and Disclosures Requiring Authorization

RTC may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorizationis written permission above and beyond the general consent that permits only  specific disclosures. In those instances when RTC is asked for information for purposes outside of treatment, payment or  health care operations, RTC will obtain an authorization from you before releasing this information. RTC will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes your therapist has made  about your conversation during a private, group, joint, or family counseling session, which have been kept separate from the  rest of your medical record. These notes are given a greater degree of protection than PHI. 

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing.  You may not revoke an authorization to the extent that (1) RTC has relied on that authorization; or (2) if the authorization  was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim  under the policy. 

III. Uses and Disclosures with Neither Consent nor Authorization 

RTC may use or disclose PHI without your consent or authorization in the following circumstances:  

  • Child Abuse: If your therapist knows or has reason to believe a child is being neglected or physically or sexually abused,  or has been neglected or physically or sexually abused within the preceding three years, your therapist must immediately report the information to the local welfare agency, police or sheriff’s department.
  • Adult and Domestic Abuse: If your therapist has reason to believe that a vulnerable adult is being or has been maltreated, or if your therapist has knowledge that a vulnerable adult has sustained a physical injury which is not  reasonably explained, your therapist must immediately report the information to the appropriate agency in this county.  Your therapist may also report the information to a law enforcement agency. 
    Vulnerable adult” means a person who, regardless of residence or whether any type of service is received, possesses a  physical or mental infirmity or other physical, mental, or emotional dysfunction:  
    (i) that impairs the individual’s ability to provide adequately for the individual’s own care without assistance,  including the provision of food, shelter, clothing, health care, or supervision; and
    (ii) because of the dysfunction or infirmity and the need for assistance, the individual has an impaired ability to protect the individual from maltreatment. 
  • Health Oversight Activities: The Minnesota Board of Marriage & Family Therapy and the Minnesota Board of  Behavioral Health and Therapy may subpoena records from RTC if they are relevant to an investigation it is conducting. 
  • Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that RTC has provided you and/or the records thereof, such information is privileged under state law and RTC must not release this information without written authorization from you or your legally appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. Your therapist will inform you in advance if this is the case. 
  • Serious Threat to Health or Safety: If you communicate a specific, serious threat of physical violence against a specific,  clearly identified or identifiable potential victim, your therapist must make reasonable efforts to communicate this threat  to the potential victim or to a law enforcement agency. Your therapist must also do so if a member of your family or  someone who knows you well has reason to believe you are capable of and will carry out the threat. Your therapist may  also disclose information about you necessary to protect you from a threat to commit suicide.  
  • Worker’s Compensation: If you file a worker’s compensation claim, a release of information from your therapist to your  employer, insurer, the Department of Labor and Industry or you will not need your prior approval.  
  1. Patient’s Rights and Clinician’s Duties

Patient’s Rights: 

  • Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of protected health  information. However, RTC is not required to agree to a restriction you request.  
  • Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and  receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a  family member to know that you are being seen at RTC. On your request, RTC will send your bills to another address.)  
  • Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI (and psychotherapy notes) in  RTC’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the  record. Your therapist may deny your access to PHI under certain circumstances, but in some cases, you may have this  decision reviewed. On your request, your therapist will discuss with you the details of the request and denial process.  
  • Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your  therapist may deny your request. On your request, your therapist will discuss with you the details of the amendment process.  
  • Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have  neither provided consent nor authorization (as described in Section III of this Notice). On your request, your therapist will discuss with you the details of the accounting process.  
  • Right to a Paper Copy – You have the right to obtain a paper copy of the notice from RTC upon request, even if you have  agreed to receive the notice electronically.

Clinician’s Duties: 

  • RTC is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. 
  • RTC reserves the right to change the privacy policies and practices described in this notice. Unless we notify you of such  changes, however, we are required to abide by the terms currently in effect.  
  • If we revise our policies and procedures, we will send you a copy by mail or give you a copy in session. 

V. Questions and Complaints 

If you have questions about this notice, disagree with a decision your therapist makes about access to your records, or have other concerns about your privacy rights, you may contact the clinic owner, Jeb Sawyer, at 612-483-4994.  If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint to:  

Jeb Sawyer, MA, LMFT  
5407 Excelsior Blvd, Suite B 
St Louis Park, MN 55416 

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request. 

You have specific rights under the Privacy Rule. Your therapist will not retaliate against you for exercising your right to file a  complaint. 

  1. Effective Date, Restrictions and Changes to Privacy Policy 

This notice will go into effect on 4/14/03. 

RTC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that your therapist may maintain. RTC will provide you with a revised notice by mail or in session.

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