Effective Date: July 24, 2024

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

My Pledge Regarding Health Information

As a Licensed Professional Counselor (LPC) in Georgia, I understand that your health information is personal. I am committed to protecting your health information and ensuring its confidentiality. I create a record of the care and services you receive from me to provide you with quality care and to comply with legal requirements. This notice applies to all the records of your care generated by my practice. This notice outlines how I may use and disclose your health information and explains your rights regarding this information. I am required by law to:

• Ensure that protected health information (PHI) that identifies you is kept private.
• Provide you with this notice of my legal duties and privacy practices with respect to your health information.
• Follow the terms of the notice currently in effect.

I reserve the right to change the terms of this Notice. Any changes will apply to all information I have about you. The updated Notice will be available upon request, in my office, and on my website.

How I May Use and Disclose Health Information About You

The following categories describe different ways I may use and disclose your health information. For each category, I will provide examples. Not every use or disclosure in a category will be listed, but all permitted uses and disclosures will fall within one of these categories.

For Treatment, Payment, or Health Care Operations

Federal privacy rules allow health care providers who have a direct treatment relationship with the patient to use or disclose the patient’s personal health information without the patient’s written authorization to carry out the health care provider’s own treatment, payment, or health care operations. I may also disclose your PHI for the treatment activities of any health care provider. For example, if a clinician were to consult with another licensed health care provider about your condition, I may use and disclose your PHI to assist in the diagnosis and treatment of your mental health condition.

Lawsuits and Disputes

If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to notify you about the request or to obtain an order protecting the information requested.

III. Certain Uses and Disclosures Require Your Authorization

Psychotherapy Notes

I keep “psychotherapy notes” as defined in 45 CFR § 164.501. Any use or disclosure of such notes requires your authorization unless the use or disclosure is:

• For my use in treating you.
• For my use in training or supervising mental health practitioners to improve their skills.
• For my use in defending myself in legal proceedings instituted by you.
• For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
• Required by law and limited to the requirements of such law.
• Required for certain health oversight activities.
• Required by a coroner performing duties authorized by law.
• Necessary to help avert a serious threat to the health and safety of others.

Marketing Purposes

I will not use or disclose your PHI for marketing purposes.

Sale of PHI

I will not sell your PHI in the regular course of my business.

Certain Uses and Disclosures Do Not Require Your Authorization

Subject to certain limitations in the law, I can use and disclose your PHI without your authorization for the following reasons:

• When required by state or federal law.
• For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
• For health oversight activities, including audits and investigations.
• For judicial and administrative proceedings, including responding to a court or administrative order.
• For law enforcement purposes, including reporting crimes occurring on my premises.
• To coroners or medical examiners performing duties authorized by law.
• For research purposes, including studying and comparing the mental health of patients who received different forms of therapy.
• For specialized government functions, including military missions, protecting the President, conducting intelligence operations, or ensuring the safety of correctional institutions.
• For workers’ compensation purposes, to comply with laws.
• For appointment reminders and health-related benefits or services.

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

Disclosures to Family, Friends, or Others

I may provide your PHI to a family member, friend, or other person involved in your care or payment for your care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

Your Rights Regarding Your PHI

The Right to Request Limits on Uses and Disclosures of Your PHI

You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request if I believe it would affect your care.

The Right to Request Restrictions for Out-of-Pocket Expenses Paid in Full

You have the right to request restrictions on disclosures of your PHI to health plans if the PHI pertains solely to a health care item or service that you have paid for out-of-pocket in full.

The Right to Choose How I Send PHI to You

You have the right to ask me to contact you in a specific way or to send mail to a different address. I will agree to all reasonable requests.

The Right to See and Get Copies of Your PHI

Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record or a summary within 30 days of receiving your written request. I may charge a reasonable, cost-based fee.

The Right to Get a List of the Disclosures I Have Made

You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with authorization. I will respond to your request within 60 days. The list will include disclosures made in the last six years unless you request a shorter time. I will provide the list at no charge once a year, but I will charge a reasonable fee for additional requests.

The Right to Correct or Update Your PHI

If you believe there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

The Right to Get a Paper or Electronic Copy of this Notice

You have the right to get a paper copy of this Notice, and you have the right to get a copy by e-mail. Even if you have agreed to receive this Notice via e-mail, you can also request a paper copy.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you acknowledge that you have received a copy of the HIPAA Notice of Privacy Practices.

If you have any questions about this notice, please contact Rethinking Me Therapy: [email protected]