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 AND KEEP A COPY FOR YOUR RECORDS.

I. OUR RESPONSIBILITIES: We are required by applicable federal and state law to maintain the privacy of your health information and inform you of our privacy practices, legal obligations, and your rights concerning your health information. We reserve the right to change this Notice of Privacy Practices and to make any new Notice of Privacy Practices effective for all protected health information that we maintain. Any new Notice of Privacy Practices adopted will be posted on our website and can be made available at your next appointment.

II. WHAT IS "PROTECTED HEALTH INFORMATION" (PHI)? Protected health information ("PHI") is demographic and individually identifiable health information that will or may identify the client and relates to the client's past, present or future physical or mental health or condition and related health care services.

USES AND DISCLOSURES OF INFORMATION: Under federal law, we are permitted to use and disclose protected health information, excluding psychotherapy notes, without authorization for treatment, payment and health care operations.

III. WHAT DOES "HEALTH CARE OPERATIONS" INCLUDE? Health care operations include activities such as communications among health care providers, conducting quality assessment and improvement activities; evaluating the qualifications, competence, and performance of health care professionals; training future health care professionals; other related services that may be a benefit to you such as case management and care coordination; contracting with insurance companies: conducting medical review and auditing services; compiling and analyzing information in anticipation of or for use in legal proceedings; and general administrative and business functions.

IV. HOW MEDICAL INFORMATION MAY BE USED FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS

  - Medical information may be used to justify needed patient care services, (i.e., treatment protocols).

  - We will use medical information to establish a treatment plan.

  - We may disclose protected health information to another provider for treatment (i.e. referring physicians, specialists and providers, therapists, etc.)

  - We may use medical information for the supervision of LPC and LMSW Interns or in consultation with other professionals.

  - We may submit claims to your insurance company containing medical information and we may contact their utilization review department to receive pre-certification (prior approval for treatment). We will submit only the minimum amount of information necessary for this purpose.

  - We may use the emergency contact information you provided to contact you if the address of record is no longer accurate.

  - We may contact you to remind you of your appointment by calling, emailing, or texting you.

  - We may contact you to discuss treatment alternatives or other health related benefits that may be of interest.

V. WHAT ARE PSYCHOTHERAPY NOTES? Psychotherapy notes are notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are separated from the rest of the patient's medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Psychotherapy notes will be used only by your clinician and will not otherwise be used or disclosed without your written authorization.

VI. WHAT IS PSYCHOSOCIAL INFORMATION? Psychosocial information is information provided regarding your social history and counseling or psychiatric services you have received before treatment with me.

VII. SHARING INFORMATION WITH BUSINESS ASSOCIATES

There are some services provided through contracts with business associates. Examples include billing services and receptionist services. When these services are contracted, we may disclose information as relevant to the business associate so that they can perform the job we have contracted them to do.

VIII. WHEN IS MY AUTHORIZATION / CONSENT NOT REQUIRED?

The law requires that some information may be disclosed without your authorization in the following circumstances:

  - In case of an emergency

  - If you appear to pose an imminent threat to yourself or others, in order to reduce the likelihood of harm

  - When there are communication or language barriers

  - When ordered to do so by a court, grand jury, or administrative tribunal. Under certain conditions, we may disclose information in response to a subpoena or other legal process, even without a court order

  - When required by law

  - When there are risks to public health

  - To conduct health oversight activities

  - To report suspected child abuse or neglect or abuse/neglect to other disabled persons

  - To specified government regulatory agencies including proof of compliance with regulations that safeguard your information

  - To coroners, funeral directors, and for organ donation

IX. YOUR PRIVACY RIGHTS

The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

1. You have the right to inspect and copy your health information.

This means you may inspect and obtain a copy of your PHI that is contained in a "designated record set" for so long as we maintain the PHI. A designated record set contains medical and billing records and any other records that we use in making decisions about your healthcare. All requests must be in writing. We reserve the right to deny access to your records. We will charge a fee for the costs of copying and sending you any records requested. You may not however, inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and certain PHI that is subject to laws that prohibit access to that PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.

2. You have the right to request a restriction of your health information.

This means you may ask us to restrict or limit the medical information we use or disclose for the purposes of treatment, payment or healthcare operations. We are not required to agree to a restriction that you may request. We will notify you if we deny your request. If we do agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction (such as non-disclosure to health insurance) by contacting your counselor.

3. You have the right to request to receive confidential communications by alternative means or at alternative locations.

We will accommodate reasonable requests. We may also condition this accommodation by asking you for an alternative address or other method of contact. We will not request an explanation from you as the basis for the request. Requests must be made in writing to our Privacy Officer.

4. You have the right to request amendments to your health information.

This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with our Privacy Office and we may prepare a rebuttal to your statement and will provide you with a copy of this rebuttal. If you wish to amend your PHI, please contact our Privacy Officer. Requests for amendment must be in writing and explain why the information should be amended.

5. You have the right to receive an accounting of disclosures of your health information.

You have the right to request an accounting of certain disclosures of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, to family or friends involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years.

6. You have the right to receive a paper copy of this Notice of Privacy Practices.

X. WHAT IF I HAVE A QUESTION / COMPLAINT?

If you have questions regarding your privacy rights, please speak to your counselor directly. If you believe your privacy rights have been violated, you may file a complaint by contacting your counselor, or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. The address for the Secretary of the Department of Health and Human Services is:

Office of Civil Rights, U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth St., S.W., Atlanta, GA 30303-8909, (404) 562-7886 (phone), (404) 562-7881 (fax), (404) 331-2867 (TDD), www.hhs.gov/ocr/hipaa

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

In our Notice of Privacy Practices, we provide you information about how Life by Design Wellness can use or disclose your mental health and medical information. As described in our Notice of Privacy Practices, we request your consent for any use or disclosure of mental health and medical information necessary to carry out treatment, payment or health care operations. Be advised that my Notice of Privacy Practices is subject to change. The most recent version will always be at my website at www.210Living.org. If you have any questions about my Notice of Privacy Practices or if you need to request a copy, please contact me at the address and /or phone number below.

You have the right to revoke this Consent in writing at any time, except where we have already used or disclosed your health information in reliance upon this Consent.

I acknowledge receipt of the Notice of Privacy Practices of Life by Design Wellness and consent to the use and disclosure of my personal health information for treatment, payment or health care operations, as described in the Notice of Privacy Practices.

This Notice is effective as of October 1, 2022.