Over 30 Years of Service to the Mental Health Community

MaMHCA: Massachusetts Mental Health Counselors Association


Practice Updates

Bookmark PRINT PAGE

Practice Forms

September 2015

Sample LMHC - Physician Communication Update form (PDF)      

 

January 2015

HIPAA 2015 Policies and Forms                                                              

MaMHCA has collaborated with NASW-MA to have this set of HIPAA forms commonly used in private practice reviewed for MA legal standards. These forms cover Authorizations to Disclose Personal Health Information (PHI), Notices of Privacy Practices, Request for Restrictions of PHI Disclosure, Breach of PHI Notification Forms, forms for use with Business Associates. These forms are available to MaMHCA Members Only, Please do not share with non-members

A. Authorization to Disclose Personal Health Information (PHI)
1. Policy re Authorization to Disclose PHI
2. Sample Standard Authorization to Disclose Mental Health Treatment Information
3. Sample Standard Authorization to Disclose Substance Abuse Treatment Information

B. Notice of Privacy Practices
4. Policy re Notice of Privacy Practices
5. Instructions: For Using the Notice of Privacy Practices
6. Sample Notice of Privacy Practices
7. Sample Receipt and Acknowledgement of Privacy Notice

C. Request for Restrictions of PHI Disclosure
8. Policy on Client Request for Restriction on Use or Disclosure of PHI
9. Sample Client Request for Restriction on Use or Disclosure of PHI

D. Breach of PHI
10. Sample Breach of PHI Notice to State and Federal Officials
11. Sample Breach of PHI Notice to Patient/Client
12. Authorization Contact by Telephone/Verbally in Event of Breach of PHI

E. Accounting of Disclosures
13. Policy re Accounting of Disclosures Log
14. Accounting of Disclosures Log

F. Business Associates
15. Policy re Business Associate Agreement
16. Sample Business Associate Agreement