ASAP Disclosures & Informed Consent

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Informed Consent

Welcome to Adolescent Substance Abuse Programs, Inc. (ASAP). This document contains important information about the professional services and business policies of ASAP. It also includes summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is important that you understand them. When you sign this document, it will also represent an agreement between you and ASAP. If at any time you have questions, please feel free to ask the ASAP staff.

Behavioral Health Services

ASAP provides both substance use disorder and general mental/behavioral health services for children, adolescents, and young adults. ASAP staff members are professionals trained to deliver these services or supervised in accordance with state requirements. Services offered include psychological assessment, testing, individual and group psychotherapy, referral and psychiatric liaison. These services offer both benefits and risks. Risks of receiving psychological services include the experience of uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of mental health services involves discussing the unpleasant aspects of your life. However, mental health treatment has been shown to be beneficial for those who undertake it. Therapy often leads to a significant reduction in distress, increased satisfaction in relationships, improved personal awareness and insight, increased skills to managing stress and finding resolution to problems. While ASAP cannot guarantee these benefits, it is our desire, to work with you to attain your personal goals for testing and/or treatment.

Your relationship with ASAP and our clinicians is a professional relationship that exists exclusively for behavioral health treatment. These relationships function most effectively when it remains strictly professional. ASAP can provide the best care by focusing solely on therapy and avoiding any type of social or business relationship.

Appointments

The time set for your appointments will be jointly agreed upon between you and your therapist. For cancellation, ASAP requires you provide 24-hour’s notice. Except for a valid emergency, ASAP will still expect you to pay the amount(s) identified by the formal fee agreement If you miss a session without cancelling, or cancel with less than 24-hour notice. Please note that insurance companies will not reimburse ASAP or a client for cancelled sessions; thus, you will be responsible for the fees as described on the agreement. When possible, ASAP will find another time to reschedule your appointment. In addition, you are responsible for coming to appointments on time; if you are late, your appointment will still need to end on time.

Professional Fees

A comprehensive list of fees is listed on a separate form. If you would like a copy of the ASAP fee agreement, please ask your clinician and they will provide it to you.

Insurance

If you have a health insurance policy, it often will provide some coverage for mental health treatment. With your permission, ASAP works to ascertain information about your coverage as well as provide you with superbills or file claims as appropriate. Ultimately, you are responsible for knowing the extent of your coverage and for informing ASAP if and when your coverage changes. Health insurance benefits are extremely complex and sometimes it is difficult to determine how much coverage is available. Some policies also require pre-authorization for services, without which they may refuse to provide reimbursement for mental health services. This may require ASAP to contact your insurance to obtain authorization for treatment. While much can be accomplished in the short-term treatment covered by insurance, many clients feel they need additional services after their benefits end. Some insurance plans will not cover any services at this point – if this is the case ASAP will work to find options for your care.

It is important to note that insurance companies require a clinical diagnosis (the technical term to describe the nature of problems that bring a person in for mental health services). All diagnoses are drawn from the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders). There is a copy of this manual at ASAP. If you would like more information about diagnosis in general, or your specific diagnosis, please ask your ASAP point of contact. In addition to diagnosis, sometimes insurance companies require additional clinical information such as treatment plans, summaries, or copies of your record (this is quite rare). This information will become a part of the insurance company files and will probably be stored in a computer. In some case, (however rare) they may share information with a national medical information databank. Upon request, you will be provided a copy of any report ASAP submits. By signing this agreement, you agree that ASAP can provide requested information to your carrier if you plan to pay with insurance.

ASAP is committed to providing you with transparent information about your insurance benefits. If you need additional information please call ASAP administrative staff at (513) 792-1272 for further guidance. Should we be unable to provide you with the information you need, we will work to redirect you to the appropriate source at your insurance company who can help.

Professional Records

ASAP is required to maintain appropriate records for the behavioral health services provided. Your records are maintained in a secure location on the premises. ASAP professionals keep brief records noting each session, the reasons for seeking services, goals and progress set for any treatment, diagnosis, topics discussed, as well as medical, social, and treatment history. This also includes records received from other providers, copies of records ASAP has sent to others (with your consent), and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to an untrained reader. For this reason, ASAP recommends that you initially review them with your ASAP provider or have them forwarded to another mental health professional. If ASAP refuses your request for access to your records, you have a right to have ASAP’s decision review by another mental health professional, which can be discussed upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request. Fees associated with transfer of clinical records are listed on the ASAP fee agreement, a copy of which can be provided to you as part of this orientation. In the absence of a superseding requirement, ASAP retains full clinical records for 7 years (per state law) after the last date of service for adults or for 3 years after a minor reaches the age of majority, whichever is later.

Confidentiality

The current section involves your privacy rights and describes how information about you may be disclosed, and how you can obtain access to this information. Please review it carefully.

As a rule, ASAP will disclose no information about you, or that you received services through ASAP without written consent. The formal records kept by ASAP describe services provided and dates of those services, diagnosis, functional status, symptoms, prognosis and progress, as well as any psychological testing reports and data. Health care providers are legally allowed to use or disclose records for treatment, payment, and health care operations purposes. However, ASAP does not routinely disclose information in these circumstances and will seek verbal or written authorization to do so. As always, you may revoke your permission for disclosure at any time by writing or contacting ASAP. If you choose to do this, you will be expected to reimburse ASAP at each session for the full amount of the session. This is because we will no longer have your consent to bill your insurance company.

Limits to Confidentiality

There are important exceptions to the general rule of confidentiality (i.e., times in which the disclosure of PHI is necessary) – some that are needed to provide a high quality of care and others that are mandated by state and federal law. If you wish to receive mental health services at ASAP, you must sign the attached form indicating an understanding of these policies about the limits of confidentiality. These exceptions will be noted before you begin services with ASAP and can reviewed at any time.

ASAP may use or disclose records or other information about you without your consent or authorization in the following circumstances either by policy or because legally required:

Emergency

If you are involved in a life-threatening emergency and ASAP cannot ask for permission, ASAP may need to share information that is reasonably expected to be helpful to you. This includes report to proper authorities if you are at risk to harm yourself or others to help you receive care to address an acute emergency.

Child Abuse Reporting

If there is reason to suspect that a minor is abuse or neglected, ASAP is required by law to immediately make a report and provide relevant information to appropriate authorities.

Adult Abuse Reporting

If there is reason to suspect that an elderly or incapacitated adult is abused, neglected, or exploited, ASAP is required by law to immediately make a report to appropriate authorities.

Health Oversight

State law requires psychologists to report misconduct by a health provider of their own profession. By policy, ASAP also retains the right to report misconduct by health providers of other professionals. By law, if you describe unprofessional conduct by another mental health provider of any profession, ASAP is required to explain to you how to make such a report. If you yourself are a health care provider, ASAP is required by law to report to your licensing board that you are in treatment at ASAP if your provider believes that your condition places the public at risk. State licensing boards have the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.

Court Proceedings

If you are involved in a court preceding and a request is made for information about your diagnosis, evaluation, and treatment and the records thereof, such information is privileged under state law, and ASAP will not release information unless you provide written authorization or a judge issues a court order. If ASAP receives a subpoena for records or testimony, ASAP will notify you so you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, ASAP is required to place said records in a sealed envelope and provide them to the Clerk of Court. Protections of privilege may not apply if ASAP performs an evaluation for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.

Threat to Health or Safety

Under law, if ASAP practitioners are engaged in professional duties and you communicate a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and it is believed that you have the intent and ability to carry out that threat immediately or imminently, ASAP is legally required to take steps to protect third parties. These precautions may include:

Warning potential victim(s), or the parent or guardian of the potential victim(s), if under 18
Notifying a law enforcement officer.
Seeking your hospitalization.

In addition, ASAP may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can be required to provide your records to the magistrate, your attorney, or guardian ad litem, a CSB evaluator, or a law enforcement officer, whether you are a minor or an adult.

Workers Compensation

If you file a worker’s compensation claim, ASAP is required by law, upon request with a court order, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.

Records of Minors

Special rules and regulation apply to the issue of confidentiality with minors. The purpose of meeting with ASAP professionals is to provide help with problems that are keeping a person from being successful in important areas of life. Some clients may come to ASAP because they want to talk about these problems; others may be attending because others have concerns about you. When meeting with ASAP professionals, we will discuss these issues. It is important that children/teens feel comfortable talking about these issues to make plans for improving them. Sometimes, this will include things that children/teens do not want parents or guardians to know about. For most people, knowing that what they say will be keep private helps them feel more comfortable and develop trust with their mental health provider. Privacy, also called confidentiality is an important part of the process.

As a general rule, ASAP will keep information shared with its providers confidential, unless there is verbal or written consent to disclose certain information. There are important exceptions to this rule that are important for children/teens to understand before you share this information at ASAP. In some situations, the law requires ASAP to disclose this information whether or not permissions have been granted. Some of these situations are listed below:

You disclose a plan to cause serious harm or death to yourself, and it is believed that you have the intent and ability to carry out this threat in the very near future. ASAP must take steps to inform your parent/guardian of what you said and how serious this threat appears to be. ASAP must make sure that you are protected from harming yourself.
You discuss a plan to cause serious harm or death to someone else who can be identified, and it is believed that you have the intent and ability to carry this threat out in the very near future. In this situation, ASAP must inform your parent/guardian as well as inform the person you intend to harm.
You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. In these situations, your ASAP professional will use judgment to decide whether a parent or guardian should be informed.
- This includes use of drugs and alcohol to a degree that could cause serious physical or emotional consequences.
You report that you are being abused-physically, sexually, or emotionally: or that you have been abused in the past. In this situation, ASAP is required to report this to Hamilton County Job and Family Services.
You are involved in a court case and request is made for information about any assessment or treatment received. If this occurs, ASAP will not disclose information without your verbal/written agreement unless the court requires it, ASAP will do all possible within the law to protect your confidentiality, and ASAP is required to disclose information, you will be informed it is happening

Communicating with Parents/Guardians of minors or impaired/ developmentally disabled adults

Except for situations such as those mentioned above, ASAP will not disclose information to your parent/guardian specific things you share in private therapy sessions. This includes activities and behavior that your parent/guardian would not approve of –or would be upset by –but that do not put you at risk of serious and immediate harm. However, if your risk-taking behavior becomes more serious, ASAP will use judgment to decide whether this constitutes serious and immediate danger. If your ASAP provider feels that you are in such danger, this information will be provided to your parent/guardian. ASAP will make efforts to help you communicate such issues to your parents in a way that helps foster trust in this relationship. If you refuse to do so, ASAP will have no other choice but to provide the information directly to your parent/guardian.

It is important to note that you may be asked to provide urine drug screens while in treatment. The results from these screens will be made available and discussed with your parents relative to your overall goals in treatment.

Client Rights and Responsibilities

A copy of the patient’s rights and provider’s duties is offered to clients during initial contact and more thoroughly details this agreement regarding confidentiality.

Waitlist Policy

Should ASAP be running programs at capacity and immediate admission to programming be unavailable – ASAP will provide an expected date for initiation of service. Families will be contacted by phone and/or email when a spot becomes available. If parents/clients do not respond within 48 hours, or if they are unable to begin within 1 week of contact date, they will be moved back on the waitlist and the spot will be offered to the next client/family.

Contacting ASAP Professionals

ASAP providers are often not immediately available by phone as they are often with clients or otherwise unavailable. At these times, you may leave a message on our confidential voicemail and your call will be returned as soon as possible. It may take a day or two for non-urgent matters. If, for any unseen reasons, you do not hear from your ASAP contact or your ASAP contact is unable to reach you, and you feel you cannot wait for a return call/you feel unable to keep yourself safe:

Call 513-281-CARE
Text “4 HOPE” to 839863
Go to your local hospital emergency room
Call 911 or 988 ask to speak to a mental health worker on call

Consent for Communication

As part of receiving treatment at ASAP, I understand that at times staff will need to communicate information to me via phone, mail, email, or fax. I have been provided information about the risks associated with communicating with telecommunications and approve ASAP to contact me with information via the following channels:

Phone
Mail
Email
Fax

Consent/Assent for Services

Your signature(s) below indicate that you have read this agreement and was offered/received a copy of the ASAP privacy practices and client rights and responsibilities. I agree to all terms stated in this document.

42 CFR Part 2/Mandatory Disclosures

The following information is provided to you in compliance with state and federal laws. Please read this information and retain a copy. If you need additional copies, we are happy to provide them to you.

Federal Regulation 42 CFR Part 2

According to Federal Regulation 42 CFR Part 2, the confidentiality of alcohol and drug abuse client records maintained by a program is protected by Federal law and Regulations.

42 CFR Part 2 protects clients who have applied for, participated in, or received an interview, counseling, or any other service from a federally assisted alcohol or drug abuse program, identified as an alcohol or drug client during an evaluation of eligibility for treatment. Applicants are included, whether or not they are admitted to the program. However, a person who does not show up for an appointment that was arranged by a third party is NOT a client.

42 CFR Part 2 protects client identifying information that would identify a client as an alcohol or drug client, either directly or indirectly.

Any information, whether oral or written, that would directly or indirectly reveal a person’s status as a current or former client.

Records protected from unauthorized disclosure include any information acquired about a client – including client’s identity, address, medical or treatment information and all communications made by him or her to program staff – whether in writing or recorded in some other form. This means that the memories and impression of program staff are considered “records” protected by the regulations even if they are never recorded in any form.

42 CFR Part 2 protects clients who have applied for, participated in, or received an interview, counseling or any other service from a federally assisted alcohol or drug abuse program, including someone who, after arrest on a criminal charge, is identified as an alcohol or drug client during an evaluation of eligibility for treatment. Applicants are included, whether or not they are admitted to a program.

42 CFR Part 2 defines “disclosures” as any communication of information about an identified client or of information that would identify someone as a client or as a drug or alcohol abuser, including verification of information that is already known by the person making the inquiry.

Restrictions on disclosures pertain to disclosures made to third parties as well as disclosures made within the program.

Implicit as well as explicit disclosures are prohibited under 42 CFR Part 2. As an example, one may not disclose that an individual is attending a program that is publicly recognized as a place where only alcohol or drug abuse services are provided, unless the individual consents in accordance with regulations or unless the disclosure fits within one of the exceptions to the general rule prohibiting disclosure.

If a program receives a request for disclosure of an individual’s records that is not permitted by the regulations, it must decline to make the disclosure, and must be sure to do so in a way that does not disclose that the individual has ever been diagnosed or treated for an alcohol or drug problem.

Appropriate response to request for protected information: “federal law prohibits me from disclosing that information.”

Grievance Procedure

ASAP is committed to providing you with the highest quality service possible. However, should you feel that one or more of your rights (or the rights of your child) has been violated, you can receive assistance in filing a grievance with the Client Rights Officer (CRO):

David Baum, Psy.D., LICDC
9403 Kenwood Rd. C-212 Cincinnati, OH 45242
513-792-1272 Monday-Friday | Noon to 7 PM

Process

The CRO will meet with you and/or your representative to determine the nature of your grievance. The CRO will gather initial information regarding the specific incident(s), including dates, places, names of person(s) involved and names of possible witnesses. Upon filing the grievance, you will also be given an explanation of the grievance procedure, which includes the opportunity for you to file a grievance with other agencies beyond ASAP. A time line for resolution of the grievance will be developed that is not to exceed twenty working days from filing the grievance.

Timeline

Within 2-3 days of the meeting with you, the CRO will initiate an investigation on your behalf.
A written statement of proposed resolution will be submitted within 5-7 days.
If unresolved, you will have the opportunity to appeal and meet with an impartial decision-maker.
If you request, the CRO will represent you at a second meeting.
Within 10 working days, you shall receive a written statement of the proposed resolution.
If there is no resolution, you will be informed of your option to file grievance(s) with a list of agencies that the CRO will provide to you.

A copy of this grievance procedure is posted publicly by ASAP and a copy is available to you. The CRO is also available to you. If the CRO is the subject of a grievance, alternative arrangements will be made. ASAP employees are trained in this grievance procedure to be able to assist clients. ASAP will take all steps to assure compliance with this procedure.

Client Grievance Procedure

All grievances must be written, dated, and signed by the client or a parent/guardian filing the grievance on behalf of the client and should include the date, approximate time, description of the incident and names of the individuals involved in the incident/situation being grieved. Grievances should be given to the ASAP Director who acts as the client rights officer, or in the event the client rights officer is not on the premises, the grievance can be given to Dr. Richard Baum. Any program supervisor will assist you in filing a grievance upon your request. All grievance, including a copy of the grievance, documentation reflecting the process used and resolution/remedy of the grievance and documentation, if applicable, of extending the time period for resolving the grievance beyond twenty-one calendar days.

Within three working days of receiving the grievance, ASAP will provide the client with a written acknowledgement that includes: a) the date the grievance was received, b) a summary of the grievance, c) an overview of the grievance investigation, d) a timetable for completing the investigation and notification of the resolution, and e) the treatment provider contact person’s name, address, and phone number.

Within twenty-one calendar days of receiving the grievance, the program will make a resolution decision on the grievance. Any exceptions that cause this time period to be extended will be documented in the grievance file and written notification will be given to the client or persons filing the grievance on the client’s behalf.

At any time, clients or persons filing grievances on the clients’ behalf have a right to file a grievance with any of the organizations listed below:

Ohio Legal Rights Services
*Includes Advocacy for the Disabled
50 West Broad Street, Suite 1400
Columbus, Ohio 43215-5923
Phone: 614.466.7264
Toll Free: 800.282.9181

Hamilton County ADAS Board
830 Main Street, Suite 300
Cincinnati, Ohio 45202
Phone: 513.621.7202
Fax: 513.621.4116

Office for Civil Rights
US Department of Health and Human Services
233 North Michigan Avenue, Suite 240
Chicago, Illinois 60601
Voice Phone: 312.886.2359
TDD: 312.353.5693

Ohio Mental Health and Addiction Services
30 East Broad Street, 8th Floor
Columbus, Ohio 43215-3413
Phone: 614.466.2596

Counselor and Social Worker Board
77 South High Street, 16th Floor
Columbus, Ohio 43215-6108
Phone: 614.466.0912

Office of Criminal Justice Services
400 East Town Street, Suite 300
Columbus, Ohio 43215
Phone: 614.466.7782

State Board of Psychology
77 South High Street, 18th Floor
Columbus, Ohio 43215-6108
Phone: 614.466.8808

CDC’s National Prevention Information Network Fact Sheet for Public Health Personnel
CDC National STD/HIV Hotline – (800) 458-5231 or www.cdcnpin.org

Male Latex Condoms and Sexually Transmitted Diseases

In June 2000, the National Institutes of Health (NIH), in collaboration with the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the United States Agency for International Development (USAID), convened a workshop to evaluate the published evidence establishing the effectiveness of latex male condoms in preventing STDs, including HIV. A summary report from that workshop was completed in July 2001 (http://www.niaid.nih.gov/dmid/stds/condomreport.pdf).

This fact sheet is based on the NIH workshop report and additional studies that were not reviewed in that report or were published subsequent to the workshop (see “Condom Effectiveness” for additional references). Most epidemiologic studies comparing rates of STD transmission between condom users and non-users focus on penile-vaginal intercourse.

Recommendations concerning the male latex condom and the prevention of sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), are based on information about how different STDs are transmitted, the physical properties of condoms, the anatomic coverage or protection that condoms provide, and epidemiologic studies of condom use and STD risk. The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual intercourse, or to be in a long-term mutually monogamous relationship with a partner who has been tested and you know is uninfected.

For persons whose sexual behaviors place them at risk for STDs, correct and consistent use of the male latex condom can reduce the risk of STD transmission. However, no protective method is 100 percent effective, and condom use cannot guarantee absolute protection against any STD. Furthermore, condoms lubricated with spermicides are no more effective than other lubricated condoms in protecting against the transmission of HIV and other STDs. In order to achieve the protective effect of condoms, they must be used correctly and consistently. Incorrect use can lead to condom slippage or breakage, thus diminishing their protective effect. Inconsistent use, e.g., failure to use condoms with every act of intercourse, can lead to STD transmission because transmission can occur with a single act of intercourse. While condom use has been associated with a lower risk of cervical cancer, the use of condoms should not be a substitute for routine screening with Pap smears to detect and prevent cervical cancer.

Sexually Transmitted Diseases, Including HIV

Latex condoms, when used consistently and correctly, are highly effective in preventing transmission of HIV, the virus that causes AIDS. In addition, correct and consistent use of latex condoms can reduce the risk of other sexually transmitted diseases (STDs), including discharge and genital ulcer diseases. While the effect of condoms in preventing human papillomavirus (HPV) infection is unknown, condom use has been associated with a lower rate of cervical cancer, an HPV-associated disease.

There are two primary ways that STDs can be transmitted. Human immunodeficiency virus (HIV), as well as gonorrhea, chlamydia, and trichomoniasis – the discharge diseases – are transmitted when infected semen or vaginal fluids contact mucosal surfaces (e.g., the male urethra, the vagina or cervix). In contrast, genital ulcer diseases – genital herpes, syphilis, and chancroid – and human papillomavirus are primarily transmitted through contact with infected skin or mucosal surfaces. Laboratory studies have demonstrated that latex condoms provide an essentially impermeable barrier to particles the size of STD pathogens.

Theoretical basis for protection: condoms can be expected to provide different levels of protection for various sexually transmitted diseases, depending on differences in how the diseases are transmitted. Because condoms block the discharge of semen or protect the male urethra against exposure to vaginal secretions, a greater level of protection is provided for the discharge diseases. A lesser degree of protection is provided for the genital ulcer diseases or HPV because these infections may be transmitted by exposure to areas, e.g., infected skin or mucosal surfaces, that are not covered or protected by the condom.

Epidemiologic studies seek to measure the protective effect of condoms by comparing rates of STDs between condom users and nonusers in real-life settings. Developing such measures of condom effectiveness is challenging. Because these studies involve private behaviors that investigators cannot observe directly, it is difficult to determine accurately whether an individual is a condom user or whether condoms are used consistently and correctly. Likewise, it can be difficult to determine the level of exposure to STDs among study participants. These problems are often compounded in studies that employ a “retrospective” design, e.g., studies that measure behaviors and risks in the past. As a result, observed measures of condom effectiveness may be inaccurate. Most epidemiologic studies of STDs, other than HIV, are characterized by these methodological limitations, and thus, the results across them vary widely–ranging from demonstrating no protection to demonstrating substantial protection associated with condom use. This inconclusiveness of epidemiologic data about condom effectiveness indicates that more research is needed–not that latex condoms do not work. For HIV infection, unlike other STDs, a number of carefully conducted studies, employing more rigorous methods and measures, have demonstrated that consistent condom use is a highly effective means of preventing HIV transmission.
Another type of epidemiologic study involves examination of STD rates in populations rather than individuals. Such studies have demonstrated that when condom use increases within population groups, rates of STDs decline in these groups. Other studies have examined the relationship between condom use and the complications of sexually transmitted infections. For example, condom use has been associated with a decreased risk of cervical cancer – an HPV associated disease.

The following includes specific information for HIV, discharge diseases, genital ulcer diseases and human papillomavirus, including information on laboratory studies, the theoretical basis for protection and epidemiologic studies.

HIV / AIDS

Latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV, the virus that causes AIDS. AIDS is, by far, the most deadly sexually transmitted disease, and considerably more scientific evidence exists regarding condom effectiveness for prevention of HIV infection than for other STDs. The body of research on the effectiveness of latex condoms in preventing sexual transmission of HIV is both comprehensive and conclusive. In fact, the ability of latex condoms to prevent transmission of HIV has been scientifically established in “real-life” studies of sexually active couples as well as in laboratory HIV/AIDS Continued: studies. Laboratory studies have demonstrated that latex condoms provide an essentially impermeable barrier to particles the size of STD pathogens. Theoretical basis for protection: latex condoms cover the penis and provide an effective barrier to exposure to secretions such as semen and vaginal fluids, blocking the pathway of sexual transmission of HIV infection. Epidemiologic studies that are conducted in real-life settings, where one partner is infected with HIV and the other partner is not, demonstrate conclusively that the consistent use of latex condoms provides a high degree of protection.

Discharge Diseases, Including Gonorrhea, Chlamydia, and Trichomoniasis

Latex condoms, when used consistently and correctly, can reduce the risk of transmission of gonorrhea, chlamydia, and trichomoniasis. Gonorrhea, chlamydia, and trichomoniasis are termed discharge diseases because they are sexually transmitted by genital secretions, such as semen or vaginal fluids. HIV is also transmitted by genital secretions.

Laboratory studies have demonstrated that latex condoms provide an essentially impermeable barrier to particles the size of STD pathogens. Theoretical basis for protection: the physical properties of latex condoms protect against discharge diseases such as gonorrhea, chlamydia, and trichomoniasis, by providing a barrier to the genital secretions that transmit STD-causing organisms. Epidemiologic studies that compare infection rates among condom users and nonusers provide evidence that latex condoms can protect against the transmission of chlamydia, gonorrhea and trichomoniasis. However, some other epidemiologic studies show little or no protection against these infections. Many of the available epidemiologic studies were not designed or conducted in ways that allow for accurate measurement of condom effectiveness against the discharge diseases. More research is needed to assess the degree of protection latex condoms provide for discharge diseases, other than HIV.

Genital Ulcer Diseases and Human Papillomavirus

Genital ulcer diseases and HPV infections can occur in both male and female genital areas that are covered or protected by a latex condom, as well as in areas that are not covered. Correct and consistent use of latex condoms can reduce the risk of genital herpes, syphilis, and chancroid only when the infected area or site of potential exposure is protected. While the effect of condoms in preventing human papillomavirus infection is unknown, condom use has been associated with a lower rate of cervical cancer, an HPV-associated disease.

Genital ulcer diseases include genital herpes, syphilis, and chancroid. These diseases are transmitted primarily through “skin-to-skin” contact from sores/ulcers or infected skin that looks normal. HPV infections are transmitted through contact with infected genital skin or mucosal surfaces/fluids. Genital ulcer diseases and HPV infection can occur in male or female genital areas that are, or are not, covered (protected by the condom).

Laboratory studies have demonstrated that latex condoms provide an essentially impermeable barrier to particles the size of STD pathogens. Theoretical basis for protection: protection against genital ulcer diseases and HPV depends on the site of the sore/ulcer or infection. Latex condoms can only protect against transmission when the ulcers or infections are in genital areas that are covered or protected by the condom. Thus, consistent and correct use of latex condoms would be expected to protect against transmission of genital ulcer diseases and HPV in some, but not all, instances.

Epidemiologic studies that compare infection rates among condom users and nonusers provide evidence that latex condoms can protect against the transmission of syphilis and genital herpes. However, some other epidemiologic studies show little or no protection. Many of the available epidemiologic studies were not designed or conducted in ways that allow for accurate measurement of condom effectiveness against the genital ulcer diseases. No conclusive studies have specifically addressed the transmission of cancroid and condom use, although several studies have documented a reduced risk of genital ulcers in settings where cancroid is a leading cause of genital ulcers. More research is needed to assess the degree of protection latex condoms provide for the genital ulcer diseases.

While some epidemiologic studies have demonstrated lower rates of HPV infection among condom users, most have not. It is particularly difficult to study the relationship between condom use and HPV infection because HPV infection is often intermittently detectable and because it is difficult to assess the frequency of either existing or new infections. Many of the available epidemiologic studies were not designed or conducted in ways that allow for accurate measurement of condom effectiveness against HPV infection.

A number of studies, however, do show an association between condom use and a reduced risk of HPV-associated diseases, including genital warts, cervical dysplasia and cervical cancer. The reason for lower rates of cervical cancer among condom users observed in some studies is unknown. HPV infection is believed to be required, but not by itself sufficient, for cervical cancer to occur. Co-infections with other STDs may be a factor in increasing the likelihood that HPV infection will lead to cervical cancer. More research is needed to assess the degree of protection latex condoms provide for both HPV infection and HPV-associated disease, such as cervical cancer.

CDC Information about Hepatitis

Hepatitis A: is a liver disease caused by the hepatitis A virus (HAV). Hepatitis A can affect anyone. In the United States, hepatitis A can occur in situations ranging from isolated cases of disease to widespread epidemics.

Hepatitis B: is a serious disease caused by a virus that attacks the liver. The virus, which is called hepatitis B virus (HBV), can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death.

Hepatitis C: is a liver disease caused by the hepatitis C virus (HCV), which is found in the blood of persons who have the disease. HCV is spread by contact with the blood of an infected person.

Hepatitis D: is a liver disease caused by the hepatitis D virus (HDV), a defective virus that needs the hepatitis B virus to exist. Hepatitis D virus (HDV) is found in the blood of persons infected with the virus.

Hepatitis E: is a liver disease caused by the hepatitis E virus (HEV) transmitted in much the same way as hepatitis A virus. Hepatitis E, however, does not occur often in the United States.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact the ASAP President, Dr. David Baum at 513.792.1272

OUR OBLIGATIONS:

ASAP is required by law to:

Maintain the privacy of protected health information
Give you this notice of our legal duties and privacy practices regarding health information about you
Follow the terms of our notice that is currently in effect

HOW ASAP MAY USE AND DISCLOSE HEALTH INFORMATION:

The following describes the ways ASAP may use and disclose health information that identifies you (“Health Information”). Except for the purposes described below, ASAP will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer.

For Treatment. ASAP may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, ASAP may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

For Payment. ASAP may use and disclose Health Information so that ASAP or others may bill and receive payment from you, an insurance company, or a third party for the treatment and services you received. For example, ASAP may give your health plan information about you so that they will pay for your treatment.

For Health Care Operations. ASAP may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, ASAP may use and disclose information to make sure the assessment you receive is of the highest quality. ASAP also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. ASAP may use and disclose Health Information to contact you to remind you that you have an appointment with us. ASAP also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. When appropriate, ASAP may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. ASAP also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

Research. Under certain circumstances, ASAP may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before ASAP uses or discloses Health Information for research, the project will go through a special approval process. Even without special approval, ASAP may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information.

SPECIAL SITUATIONS:

As Required by Law. ASAP will disclose Health Information when required to do so by international, federal, state, or local law.

To Avert a Serious Threat to Health or Safety. ASAP may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Business Associates. ASAP may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, ASAP may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Organ and Tissue Donation. If you are an organ donor, ASAP may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, ASAP may release Health Information as required by military command authorities. ASAP also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Workers’ Compensation. ASAP may release Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. ASAP may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if ASAP believes a patient has been the victim of abuse, neglect or domestic violence. ASAP will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. ASAP may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Data Breach Notification Purposes. ASAP may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, ASAP may disclose Health Information in response to a court or administrative order. ASAP also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. ASAP may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, ASAP are unable to obtain the person’s agreement; (4) about a death ASAP believes may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors. ASAP may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. ASAP also may release Health Information to funeral directors as necessary for their duties.

National Security and Intelligence Activities. ASAP may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others. ASAP may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, ASAP may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT OUT:

Individuals Involved in Your Care or Payment for Your Care. Unless you object, ASAP may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care., If you are unable to agree or object to such a disclosure, ASAP may disclose such information as necessary if ASAP determines that it is in your best interest based on our professional judgment.

Disaster Relief. ASAP may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. ASAP will provide you with an opportunity to agree or object to such a disclosure whenever ASAP practically can do so.

ASAP DOES NOT DO THE FOLLOWING UNDER ANY CIRCUMSTANCES:

Use and disclose Protected Health Information for marketing purposes
Sell your Protected Health Information to any other entity

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and ASAP will no longer disclose Protected Health Information under the authorization. But disclosure that ASAP made in reliance on your authorization before you revoked it will not be affected by the revocation.

YOUR RIGHTS:

You have the following rights regarding your Protected Health Information:

Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to: