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Privacy Policy & Clinical Services Forms

Privacy Policy Statement

                                                  Privileged Communication, Privacy & Confidentiality Statement


The information provided by and to the patient/client during treatment or assessment sessions is legally protected & confidential and cannot be released without written patient consent. However, there are exceptions; some of which are listed in section 12-43-218 of the Colorado Revised Statutes, and the Notification of Privacy Rights and Disclosure Forms you were provided, as well as other exceptions in both Colorado State and Federal law. 


 For example, mental health professionals are required to report suspected child abuse to authorities. If a legal exception to your confidentiality arises during your treatment/assessment, if feasible, you will be informed accordingly.12-43-218 of the Colorado Revised Statutes, and the Notification of Privacy Rights and Disclosure Forms you were provided, as well as other exceptions in both Colorado State and Federal law. 


Confidentiality may also be waived in the event of physical abuse and/or neglect of a child, including any past or present sexual contact with a minor. All clinicians are required by law to report such instances to the Department of Social Services and / or law enforcement. Additionally, in the event of imminent danger to yourself or another person, your provider is required by law to protect you, which may result in you being hospitalized. They also have a duty to warn anyone who may be in imminent danger as a result of your threats or frame of mind. Additionally, in some circumstances, a court may order the release of information, and records, or your provider may be ordered to testify in court. 


If the sole purpose of your professional relationship with Dr. Wylie & MPA is for a Forensic Evaluation (Including Evaluations paid for by DVR) or Service these rules may not apply. Please ask Dr. Wylie to provide you with the specific privacy, confidentiality and privilege rules that govern your situation. You have the right to receive a good faith estimate of what your healthcare services may cost. Please see the No Surprises Act for more information.


Non-Forensic Forms & Documents

Current Copies of Commonly Used Forms Can Be Downloaded Here

Personal History Checklist (PHC-A) (pdf)Download
MPA Medical Release Form (docx)Download
Adult Consent 2021 (pdf)Download
Minor Consent 2021 (pdf)Download
Telehealth Consent 2021 (pdf)Download
Detailed Patient History (pdf)Download
No Surprises Act 2023 (pdf)Download
Dr. Wylie's Disclosure (pdf)Download

Online Fillable Forms

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Mandatory Disclosure Statement (MDS)Button

All Rights Reserved 2024  

Scott D Wylie, Psy.D., MSCP, LLC   

DBA: Medical Psychology Associates 

   Privacy Policy Statement

No Surprises Act


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