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Terms and Policy


Welcome to my psychotherapy practice. This document contains important information about my professional services and business policies. This form provides you (client) with information that is additional to that detailed in the Notice of Privacy Practices. Please read it carefully and identify any questions you may have to discuss. Please initial each paragraph in the space provided indicating that you have read and understood the content of that paragraph. When you sign this document, it will represent an agreement between us.

THE PURPOSE OF THERAPY: The purpose of therapy is to support and/or create positive change so the client can experience life more fully. It provides an opportunity to better, and more deeply, understand oneself, as well as any problems or difficulties such as abandonment issues or sadness due to divorce one may be experiencing.

THE PROCESS OF THERAPY: Psychotherapy is a process in which the therapist and the client discuss a variety of issues, events, experiences and memories for the purpose of creating positive change so the client can experience life more fully. It provides an opportunity to better, and more deeply, understand oneself, as well as any problems or difficulties one may be experiencing. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors. Participation in therapy can result in a number of benefits to the client, including, but not limited to, reduced stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors, improvement in interpersonal relationships, increased comfort in social, work and family settings, increased capacity for intimacy, increased self-confidence as well as resolution of the specific concerns that led you to seek therapy. Psychotherapy requires your very active involvement, honesty, and openness in order to change. As your therapist, I will ask for your feedback and views on your therapy, your progress, and other aspects of the therapy process. Although therapy typically has a positive outcome, there is no guarantee that therapy will yield all or any of the benefits listed above.

Participating in therapy may also involve some risk or discomfort, including remembering or talking about painful memories, unpleasant events, feelings, and/or thoughts. The process may evoke feelings of sadness, anger, fear, shame, anxiety, depression, etc. At times, I may challenge some of your assumptions and/or perceptions and propose different ways of looking at, thinking about, or handling situations that can cause you to feel upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing perceptions, beliefs, behaviors, employment, substances use, schooling, housing, or relationships. Sometimes, a decision that is positive for one family member can be viewed negatively by another family member. Personal growth and change may be easy and swift at times, but it may also be slow and even frustrating. I will strive to help make your therapeutic experience as productive as possible.

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client's) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.

When disclosure is required by law: Some of the circumstances where disclosure is required by law are: when there is a reasonable suspicion of child, dependent or elder, physical or sexual abuse and/or neglect; and where a client presents a danger to self, to others: or is gravely disabled (see also Notice of Privacy Practices form)

When disclosure may be required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by your therapist. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Your therapist will not release

records to any outside party unless they are authorized to do so by all adult family members who were part of the treatment.

Confidentiality of Records & Health Insurance: Pursuant to HIPAA, your clinical file contains two types of information, 1 Protected Health Information (PHI) and a Designated Record Set. The Designated Record Set refers to information in your health record/file that can identify you. The PHI is your clinical record which includes information about your reasons for seeking therapy, a description how your problem impacts your life, your diagnosis, your treatment goals. Your medical, social and psychological history, your treatment history and treatment records that I receive from other providers, reports of professional consultations, your billing records, and reports that have been sent to anyone including your insurance carrier.

I keep a set of progress notes. These notes are for my use and are designed to assist me in tracking your treatment and providing you with the best treatment. While progress notes vary from client to client, they can include the contents of our conversations, my analysis of our conversations and how they impact on therapy.

Your health insurance carrier may require disclosure of confidential information when using your PPO coverage, or other third party payer, to process the claims. Only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly, the progress notes will not and cannot be disclosed to your insurance carrier. Your therapist has no control or knowledge over what insurance companies do with the information they submit or who has access to this information. Be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information, including a diagnosis, is entered into insurance companies' computers and will also be reported to the Congress-approved National Medical Data Bank. Any computer or database is subject to unauthorized access.

Client files and records are securely stored. I practice in the same office with another mental health professional. I do not share Protected Health Information with the other professional in my office. All mental Health professionals are bound by the same rules of confidentiality. Client files are kept for seven years after the case is completed or until a child reaches the age of 21 if the child received treatment. After the records have been stored for the scheduled amount of time, the records will be disposed of with a HIPPA compliance service. In the event of my death or my inability to authorize the release of your records, Lauren Molnar, MC, LPC will be authorized to retrieve and release the records with appropriate authorizations. She can be reached at 1536 East Maryland Ave, Phoenix, AZ 85014 323-536-2187. A request by client for his/her records must be in writing and will be released within 30 days of request.

Confidentiality of E-mail, cell phone, and faxes communication: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e- mails that go through them. Faxes can be sent erroneously to the wrong address. Please notify me at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above- mentioned communication devices. Please do not use e-mail or faxes for emergencies.

CONSULTATION: At times I find it helpful to consult with other professionals regarding a client and/or case; however, the client's name or other identifying information is never mentioned. The client's identity remains completely anonymous, and confidentiality is fully maintained. This is done to provide you with the best care possible.

DISCUSSION OF TREATMENT PLAN: Together we will develop an individualized treatment plan that outlines the primary issues you want to address, identifies treatment objectives and goals and potential outcomes. Treatment plans will be reviewed and revised if needed at least once annually. If you have any unanswered questions about the course of your therapy, the possible risks, or about the treatment plan, please ask for further explanation. You also have the right to ask about other treatments for your condition and their risks and benefits as well as referral for those services if needed or wanted. During the course of therapy, I am likely to draw on various psychological approaches according, in part, to the problem that is being treated and the assessment of what will best benefit you. Sometimes more than one approach can be helpful in dealing with a certain situation. These approaches may include, but are not limited to: cognitive-behavioral, systems/family of origin, developmental (adult/child/family), psychodynamic, somatic experiencing, behavioral, existential, biblio- therapy, or psycho-educational and use of the Daring Way Model. A separate consent will be offered for Somatic Experiencing.

CLOSURE/TERMINATION: You have the right to end therapy at any time. Ideally, this happens when the goals of therapy have been met. A closure session is recommended to review your accomplishments and to discuss supports available to maintain your growth. If you voluntarily withdraw or refuse treatment there can be consequences to your mental or physical health (i.e. your condition may worsen, you may become suicidal). Any such concerns will be discussed with you. Or if at any point during therapy, I believe I am not being effective in helping you reach your therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate treatment. In both such cases, I would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, I will talk to the new psychotherapist of your choice in order to help with the transition. If at any time you want another professional's opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and with your written consent will provide him or her with the essential information needed.

DUAL RELATIONSHIPS: A dual relationship exists when you have some type of relationship with your therapist outside the clinical setting. This may include civic and philanthropic groups, religious communities, sports leagues, etc. Appropriate dual relationships are not unethical. Therapy never involves sexual or any other dual relationship that can be exploitative in nature, or impairs your therapist's objectivity, clinical judgment, and/or therapeutic effectiveness. I will discuss with you the potential difficulties that may be involved in dual relationships and will discontinue the dual relationship if it interferes with the effectiveness of the therapeutic process.

TELEPHONE & EMERGENCY PROCEDURES: Due to my work schedule, I am often not immediately available by telephone. If you need to contact me between sessions, please leave a message on my voice mail. I will typically respond to messages within 24 hours. In case of medical emergency, or when there is immediate danger or potential for harm, please call 911. Or, if you have an emotional emergency, please call the Banner Helpline at (602) 254-4357 or the EMPACT Crisis Hotline at (480) 784-1500.

APPOINTMENTS, FEES & PAYMENTS: I reserve 50 minutes for each appointment with a client unless otherwise discussed with client. If you are unable to keep a scheduled appointment, please notify me as soon as possible. Late cancellations make it difficult to offer the appointment time to someone else. Therefore, missed appointments and cancellations made less than one full business day (24 hours) in advance of the scheduled appointment will result in you being charged in full for your reserved appointment time. Payment is expected at the time of service, unless other arrangements have been agreed upon. The cost of therapy services is your responsibility. The standard fee for a 50-minute initial intake assessment, an individual, conjoint or family counseling session is $175.00. Longer extended sessions, telephone conversations over 15 minutes, report writing and reading, attendance at meetings with other professionals you have authorized and time spent performing other services you have requested of me etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Unpaid services or balances past due over 90 days may be referred to a collection agency. If a matter goes to collection some confidential information such as your name and address will be disclosed to the collection company.

INSURANCE POLICY: I am not a contracted provider of your insurance or managed care provider. I am considered an out-of-network provider with your insurance company. If you have a Preferred Provider Plan (PPO), I will provide you with a statement (known as a superbill) which you may submit to your insurance or managed care provider to seek reimbursement of fees already paid.

LITIGATION LIMITATION: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on Maria-Victoria Munoz to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.

MEDIATION & ARBITRATION: All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Maria-Victoria Munoz and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Arizona in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Maria-Victoria Munoz can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum.

I have read the above Informed Consent for Psychotherapy Services & Office Policies carefully; I understand them and agree to comply with them.

( Type Full Name )
( Full Name )
Somatic Experiencing Consent
When appropriate, and according to my clinical judgment, I will use Somatic Experiencing (SE) in our work together. SE is a short-term naturalistic approach to the resolution and healing of trauma developed by Dr. Peter Levine and is supported by research. It is based upon the observation that wild prey animals, though threatened routinely, are rarely traumatized. Animals in the wild utilize innate mechanisms to regulate and discharge the high levels of energy arousal associated with defensive survival behaviors. These mechanisms provide animals with built-in "immunity" to trauma that enables them to return to normal in the aftermath of highly "charged" life-threatening experiences.

- SE employs awareness of body sensation to help people "renegotiate" and heal rather than re-live or re-enact trauma.

- SE's guidance of the bodily "felt sense," allows the highly aroused survival energies to be safely experienced and gradually discharged.

- SE "titrates" experience (breaks down into small, incremental steps), rather than evoking catharsis-which can overwhelm the regulatory mechanisms of the organism.

For more information about SE please note the following references:

Levine, P. and Frederick, A. (1997). Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences. Berkeley, CA: North Atlantic Books.

Kline, M. and Levine, P. (2007). Trauma Through A Child's Eyes: Awakening the Ordinary Miracle of Healing. Berkeley, CA: North Atlantic Books.

For further references and information online about Se go to:

SE can result in a number of benefits to you, such as relief of traumatic stress symptoms, increased resiliency, and resourcefulness. Like any other treatment it may also have unintended negative "side effects." It is important that you are aware that there are other forms of body-oriented and somatic psychotherapy. The United States Association of Body Psychotherapy ( is a good source of information about other modalities. Obviously, there are also many non-somatic focused forms of psychotherapy and counseling that you can choose from.

As with all therapy, it is your responsibility to tell me when you are uncomfortable with any parts of treatment. If you have any questions about SE or other treatments, please ask and I will do my best to answer your questions in full. You have the right to refuse or terminate treatment at all times, or to refuse techniques or interventions I may propose or employ. I have read the above informed consent, understand, and agree to it.
( Type Full Name )
( Full Name )


(Note to therapists: Section I below must appear in your Notice of Privacy Practices exactly as it appears hereunder.) 



By law I am required to insure that your PHI is kept private.  The PHI constitutes information created or noted by me that can be used to identify you.  It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care.  I am required to provide you with this Notice about my privacy procedures. This Notice must explain when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, or analyze information within my practice; PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside my practice. With some exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, I am always legally required to follow the privacy practices described in this Notice.

Please note that I reserve the right to change the terms of this Notice and my privacy policies at any time as permitted by law.  Any changes will apply to PHI already on file with me.  Before I make any important changes to my policies, I will immediately change this Notice and post a new copy of it in my office and on my website (if applicable).  You may also request a copy of this Notice from me, or you can view a copy of it in my office or on my website, which is located at


I will use and disclose your PHI for many different reasons.  Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of my uses and disclosures, with some examples. 

A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I may use and disclose your PHI without your consent for the following reasons:

1. For treatment. I can use your PHI within my practice to provide you with mental health treatment, including discussing or sharing your PHI with my trainees and interns.  I may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treating you, I may disclose your PHI to her/him in order to coordinate your care. 

2. For health care operations. I may disclose your PHI to facilitate the efficient and correct operation of my practice. Examples:  Quality control - I might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services.  I may also provide your PHI to my attorneys, accountants, consultants, and others to make sure that I am in compliance with applicable laws.

3. To obtain payment for treatment. I may use and disclose your PHI to bill and collect payment for the treatment and services I provided you. Example: I might send your PHI to your insurance company or health plan in order to get payment for the health care services that I have provided to you. I could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for my office.

4. Other disclosures.   Examples:Your consent isn't required if you need emergency treatment provided that I attempt to get your consent after treatment is rendered. In the event that I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) but I think that you would consent to such treatment if you could, I may disclose your PHI.

B. Certain Other Uses and Disclosures Do Not Require Your Consent. I may use and/or disclose your PHI without your consent or authorization for the following reasons:

(The following list is a compilation of federal and California laws)

1.     When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: I may make a disclosure to the appropriate officials when a law requires me to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.

2.     If disclosure is compelled by a party to a proceeding before a court of an administrative agency pursuant to its lawful authority.

3.     If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.

4.     If disclosure is compelled by the patient or the patient's representative pursuant to California Health and Safety Codes or to corresponding federal statutes of regulations, such as the Privacy Rule that requires this Notice.

5.     To avoid harm. I may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public (i.e., adverse reaction to meds).

6.     If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger.

7.     If disclosure is mandated by the California Child Abuse and Neglect Reporting law.  For example, if I have a reasonable suspicion of child abuse or neglect.

8.     If disclosure is mandated by the California Elder/Dependent Adult Abuse Reporting law.  For example, if I have a reasonable suspicion of elder abuse or dependent adult abuse.

9.     If disclosure is compelled or permitted by the fact that you tell me of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.

10.  For public health activities.  Example: In the event of your death, if a disclosure is permitted or compelled, I may need to give the county coroner information about you. 

11.  For health oversight activities.  Example: I may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization or provider.

12.  For specific government functions.  Examples: I may disclose PHI of military personnel and veterans under certain circumstances. Also, I may disclose PHI in the interests of national security, such as protecting the President of the United States or assisting with intelligenceoperations.

13.  For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research.

14.  For Workers' Compensation purposes. I may provide PHI in order to comply with Workers' Compensation laws.

15.  Appointment reminders and health related benefits or services. Examples: I may use PHI to provide appointment reminders. I may use PHI to give you information about alternative treatment options, or other health care services or benefits I offer.

16.  If an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.

17.  If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law.  Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess my compliance with HIPAA regulations.

18.  If disclosure is otherwise specifically required by law.

C. Certain Uses and Disclosures Require You to Have the Opportunity to Object.

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part.  Retroactive consent may be obtained in emergency situations.

D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections IIIA, IIIB, and IIIC above, I will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (assuming that I haven't taken any action subsequent to the original authorization) of your PHI by me.


These are your rights with respect to your PHI:

A. The Right to See and Get Copies of Your PHI.  In general, you have the right to see your PHI that is in my possession, or to get copies of it; however, you must request it in writing. If I do not have your PHI, but I know who does, I will advise you how you can get it. You will receive a response from me within 30 days of my receiving your written request. Under certain circumstances, I may feel I must deny your request, but if I do, I will give you, in writing, the reasons for the denial.  I will also explain your right to have my denial reviewed.

If you ask for copies of your PHI, I will charge you not more than $.25 per page. I may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.

B. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that I limit how I use and disclose your PHI. While I will consider your request, I am not legally bound to agree. If I do agree to your request, I will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that I am legally required or permitted to make.

C. The Right to Choose How I Send Your PHI to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via e-mail instead of by regular mail). I am obliged to agree to your request providing that I can give you the PHI, in the format you requested, without undue inconvenience.  I may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.

D. The Right to Get a List of the Disclosures I Have Made. You are entitled to a list of disclosures of your PHI that I have made. The list will not include uses or disclosures to which you have already consented, i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003.  After April 15, 2003, disclosure records will be held for six years.

I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I give you will include disclosures made in the previous six years unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no cost, unless you make more than one request in the same year, in which case I will charge you a reasonable sum based on a set fee for each additional request.

E. The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that I correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of my receipt of your request. I may deny your request, in writing, if I find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d) written by someone other than me. My denial must be in writing and must state the reasons for the denial. It must also explainyour right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and my denial be attached to any future disclosures of your PHI. If I approve your request, I will make the change(s) to your PHI. Additionally, I will tell you that the changes have been made, and I will advise all others who need to know about the change(s) to your PHI.

F. The Right to Get This Notice by E-mail. You have the right to get this notice by e-mail. You have the right to request apaper copy of it, as well.


If, in your opinion, I may have violated your privacy rights, or if you object to a decision I made about access to your PHI, you are entitled to file a complaint with the person listed in Section VI below. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If you file a complaint about my privacy practices, I will take no retaliatory action against you.


If you have any questions about this notice or any complaints about my privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me at: [insert therapist's name, address phone number, and e-mail]. 


In the case of a breach, Maria Victoria Munoz, MC, LPC requires to notify each affected individual whose unsecured PHI has been compromised. Even if such a breach was caused by a business associate, Maria Victoria Munoz, MC, LPC is ultimately responsible for providing the notification directly or via the business associate.  If the breach involves more than 500 persons, OCR must be notified in accordance with instructions posted on its website. Maria Victoria Munoz, MC, LPC bears the ultimate burden of proof to demonstrate that all notifications were given or that the impermissible use or disclosure of PHI did not constitute a breach and must maintain supporting documentation, including documentation pertaining to the risk assessment.


Generally, PHI excludes any health information of a person who has been deceased for more than 50 years after the date of death. Maria Victoria Munoz, MC, LPC may disclose deceased individuals' PHI to non-family members, as well as family members, who were involved in the care or payment for healthcare of the decedent prior to death; however, the disclosure must be limited to PHI relevant to such care or payment and cannot be inconsistent with any prior expressed preference of the deceased individual.


To implement the 2013 HITECH Act, the Privacy Rule is amended. Maria Victoria Munoz, MC, LPC is required to restrict the disclosure of PHI about you, the patient, to a health plan, upon request, if the disclosure is for the purpose of carrying out payment or healthcare operations and is not otherwise required by law. The PHI must pertain solely to a healthcare item or service for which you have paid the covered entity in full. (OCR clarifies that the adopted provisions do not require that covered healthcare providers create separate medical records or otherwise segregate PHI subject to a restrict healthcare item or service; rather, providers need to employ a method to flag or note restrictions of PHI to ensure that such PHI is not inadvertently sent or made accessible to a health plan.)

The 2013 Amendments also adopt the proposal in the interim rule requiring Maria Victoria Munoz, MC, LPC, to provide you, the patient, a copy of PHI if you, the patient, requests it in electronic form. The electronic format must be provided to you if it is readily producible. OCR clarifies that Maria Victoria Munoz, MC, LPC must provide you only with an electronic copy of their PHI, not direct access to their electronic health record systems. The 2013 Amendments also give you the right to direct Maria Victoria Munoz, MC, LPC to transmit an electronic copy of PHI to an entity or person designated by you. Furthermore, the amendments restrict the fees that Maria Victoria Munoz, MC, LPC may charge you for handling and reproduction of PHI, which must be reasonable, cost-based and identify separately the labor for copying PHI (if any). Finally, the 2013 Amendments modify the timeliness requirement for right of access, from up to 90 days currently permitted to 30 days, with a one-time extension of 30 additional days.


Maria Victoria Munoz, MC, LPC NPP must contain a statement indicating that most uses and disclosures of psychotherapy notes, marketing disclosures and sale of PHI do require prior authorization by you, and you have the right to be notified in case of a breach of unsecured PHI. 


This notice went into effect on Jan. 30, 2013

I acknowledge the terms of this notice and the privacy practices of this office.
( Type Full Name )
( Full Name )
Technology within a Therapeutic Setting Consent, Polices, Limitations, and Agreement Form 

This form is to review the limitations, risks, and benefits of technology within a therapeutic setting. This includes email, phone, text and video. The provider will ultimately determine if you are appropriate for this type of treatment. 

Benefits: The benefits to technology are: 

1. Reduces the stigma of obtaining mental health services 2. More convenient for clients to get the help they need 3. Reduces the overall costs due to not having to drive to and from and office. 4. Reduces the wait time for scheduling office appointments. 5. Increased availability of services to people who are unable to leave the home or have 

difficulties with transportation 

Limitations: It is important to note that there are limitations to technology that can affect the quality of the session(s). These limitations include but are not limited to the following: 

1. Because we are not in person, the provider has limitations to reading your body 

language, or your non-verbal reactions to what is being discussed. 2. Due to technology limitations the provider may not hear all of what you are saying. If you feel the provider has not hear you, please make sure to repeat what you were saying. 3. Technology may fail before or during the session. 4. Although every effort is made to reduce confidentiality breeches we are using technology 

platforms and the provider does not have any control over whether or not the protection of confidentiality used by the platform is working as it is supposed to be at all times. 5. The provider will inform you of which technology platforms they are using and it is your responsibility to read, understand, and agree to that platforms rules and limitations. 

Logistics: When the provider is using technology, they will be in private location to ensure your privacy. Itis your responsibility to be in a location that is safe and confidential to protect your privacy. If you choose a place where others can hear you the provider cannot be responsible for protecting your confidentiality. Every effort MUST be made on your part to protect your own confidentiality. 

Connection Lost: If we lose our connection during a video or phone session, the provider will call you to try and troubleshoot the reason for the lost connection. If the reason the connection is lost occurs on your part i.e. battery dying, bad reception, etc. you could still be charged for the entire session. If the loss for connection is a result of something caused by the provider. The provider will do everything they can to troubleshoot the problem and may offer other options such as completing the session using other technology or may need to reschedule. 

Recording of Sessions: Please note the recording of audio/video, photographing, screenshots, streaming, etc. of any kind is NOT permitted and are grounds for termination of the client-therapist relationship. 

Your Location: The provider can only practice in the state they are licensed in. That means you must reside in and be participating from the state the provider is licensed. You agree to inform the provider if your location has changed. (***You must be in the state of AZ during the time of your video session)

In Case of Emergencies: Before each session begins the provider will request the address for which you are currently located and will use this information to give to authorities in case of a crisis or emergency. If for some reason, you and provider get disconnected and you are in crisis/ emergency, you agree to call 911, go to your local emergency room immediately or contact the National Suicide Hotline 800-273-TALK (8255). If the provider has concerns about your safety including you being a danger to yourself or others at ANYTIME during a session, the provider will call 911. 

The provider is required to keep an emergency contact for you. This contact can/will be used during a crisis/emergency. 

Consent to participate in technology within a therapeutic setting:By signing below you agree that you have read and understand all of the above sections of technology within a therapeutic setting informed consent. You agree that you also understand the limitations associated technology within a therapeutic setting and consent to attend sessions under the terms described above in this document. 

****Updated Jan 13, 2021

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