Maya Moon is now following  the U.S. Department of Health, and Human Services for delivering records safely.

 Records are not provided if you as a client refuse to fill out or sign our Maya Moon Request of Records form. Clients need to understand their responsibility to follow best practices for records request.

You must to sign the below form and send it to our email address: [email protected]

Maya moon is not receiving request of your records by text, phone calls or other kind of messages.

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FORM #1

MAYA MOON COUNSELING

INFORMED CONSENT TO DELIVERY RECORDS MAIL OR EMAIL.

Health Insurance Portability and Accountability Act of 1996, Public Law 104–191 (HIPAA).

Guide to

Privacy and Security of Electronic Health Information

30

Maya Moon as a private practice follows the Health Portability and Accountability high standards for protection of records and privacy.

DATE RECORDS REQUESTED:_____________________

FIRST AND LAST NAME____________________________________

Social Security:_____________________________________________

DATE OF BIRTH:___________________________________________

Check with “X” where you would like your records to be sent by e-mail or mail.

_________EMAIL ADDRESS:__________________________________

________ADDRESS: _________________________________________

Signature of the client:________________________________

Date:____________________________________________________

If you request records by mail, it will include mailing cost and invoice  adding $0.25 per page.

There is no cost if records are sent by email.

Person has the right to request records two times per year. 

CUT PRINT AND SEND TO OUR EMAIL SIGNED

[email protected]

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1-Make sure to use clear handwriting.

2-Provide an email address that is confidential and only belongs to you.

If you are requesting the records from another office, please don't forget to add and sign the HIPPA release. 

3- Allow 2 to 3 weeks in order to receive your records. 

4- You cannot ask for records more than 2 times per year. 

5- Records are destroyed after 5 years in our system. 

6- You are not allowed to pick up records since we don't count with a permanent active physical location. 

Maya Moon is a part time practice working mostly online. 

Thank you for understanding our new policy that has in consideration the protection of your records safety, and in accordance to U.S. Department of Health.