NOTICE OF PRIVACY PRACTICES
Effective Date: 05/01/2020

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

I. OUR COMMITMENT TO YOUR PRIVACY

At Persevering Families & Counseling (PF&C), we understand that your health information is personal and confidential. We are committed to protecting your privacy and ensuring that your Protected Health Information (PHI) is handled in accordance with applicable state and federal laws, including the Health Insurance Portability and Accountability Act (HIPAA).

We maintain a record of the services provided to you, which is essential for your care and for legal compliance. This Notice explains how your health information may be used and disclosed, your rights regarding that information, and our obligations to you.

PF&C is legally required to:

• Maintain the privacy of your PHI.
• Provide you with this Notice outlining our legal duties and privacy practices.
• Abide by the terms of this Notice.
• Notify you of any changes to this Notice. Updated versions will be available upon request, in our office, and on our website.

II. HOW WE MAY USE AND DISCLOSE YOUR PHI

The law permits us to use or disclose your PHI for the following purposes without your written authorization:

1. Treatment, Payment, and Health Care Operations
We may use or disclose your PHI to provide, coordinate, or manage your mental health care. For example, if a clinician consults with another licensed provider about your condition, your PHI may be shared to assist with diagnosis or treatment. These disclosures are not restricted to the "minimum necessary" standard, as full access to your record may be required to ensure quality care.

2. Legal Proceedings
 In connection with legal matters such as lawsuits, custody disputes, allegations of abuse/neglect, or criminal/civil/family court cases, we may disclose PHI in response to a court order, administrative order, subpoena, or other lawful request. When possible, we will inform you or seek protective orders prior to disclosure.

Note: Additional fees may apply if the therapist is requested to provide written reports, phone/video consultations, or in-person testimony. Please see the court proceedings consent form: Legal Fees Concerning Court Proceedings for further details.

III. USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION

We will obtain your written authorization before using or disclosing your PHI for the following:

1. Psychotherapy Notes
 We maintain psychotherapy notes as defined by 45 CFR §164.501. These notes require your specific authorization unless the use or disclosure is:

• For your treatment.
• For training or supervision of mental health professionals.
• For legal defense by PF&C in response to a client-initiated proceeding.
• For compliance investigations by the U.S. Department of Health and Human Services.
• Required by law for oversight, public safety, or coroner activities.
  

2. Marketing
 Your PHI will not be used for marketing purposes without your written authorization.

3. Sale of PHI
 PF&C does not and will not sell your PHI.

IV. USES AND DISCLOSURES THAT DO NOT REQUIRE AUTHORIZATION

We may disclose your PHI without authorization for:

• Compliance with state or federal law.
• Reporting suspected abuse or to prevent/reduce serious threats to safety.
• Oversight activities (e.g., audits, investigations).
• Judicial and administrative proceedings.
• Law enforcement (e.g., reporting crimes on the premises).
• Coroner or medical examiner duties.
• Research purposes (with de-identified data, as applicable).
• Specialized government functions (e.g., military, national security).
• Workers’ compensation claims.
• Appointment reminders and information about services or treatment alternatives.

V. USES AND DISCLOSURES REQUIRING YOUR RIGHT TO OBJECT

Disclosure to Family and Involved Persons
 Unless you object, we may share your PHI with individuals involved in your care or payment for your care. In emergencies, your consent may be obtained after the fact.

VI. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights under HIPAA:

1. Right to Request Restrictions
 You may request limitations on how your PHI is used or disclosed. While PF&C is not obligated to agree, we will consider your request.

2. Right to Restrict Disclosures for Self-Paid Services
 If you pay out-of-pocket in full for services, you may request that your PHI not be shared with your health plan regarding those services.

3. Right to Confidential Communication
 You may request to be contacted in a specific way (e.g., by mail or phone). PF&C will honor all reasonable requests. Use of our secure client portal (SimplePractice) is required for electronic communication.

4. Right to Access Records
You may request an electronic or paper copy of your records (excluding psychotherapy notes) or request a summary. Requests will be fulfilled within 30 days and may include a reasonable fee. In certain legal circumstances, access may be delayed.Please see the court proceedings consent form: Legal Fees Concerning Court Proceedings for further details.

5. Right to an Accounting of Disclosures
 You may request a list of PHI disclosures made in the past six years, excluding disclosures made for treatment, payment, or operations. The first list is free; additional requests may incur a fee.

6. Right to Amend Records
 If you believe your record is incorrect or incomplete, you may request a correction. PF&C will respond in writing within 60 days. If denied, you will be informed of the reason.

7. Right to Receive a Copy of This Notice
 You may request a paper or electronic copy of this Notice at any time. For paper copies, it is also available at our office: 516 Innovation Dr., Suite 304, Chesapeake, VA 23320.

ACKNOWLEDGMENT OF RECEIPT

By signing below, I acknowledge that I have received, read, and understand the Notice of Privacy Practices provided by Persevering Families & Counseling (PF&C). I understand the following:

• This Notice describes how my Protected Health Information (PHI) may be used and disclosed for the purposes of treatment, payment, and health care operations.
• I have the right to request restrictions on certain uses and disclosures of my PHI.
• I have the right to access, inspect, and request a copy of my health records.
• I have the right to request an amendment to my PHI and to receive an accounting of certain disclosures.
  
• I understand that additional fees may apply in legal matters requiring documentation or testimony, as outlined in the Legal Fees Concerning Court Proceedings 

CLIENT NAME (PLEASE PRINT): ______________________________

CLIENT SIGNATURE (ADULTS ONLY): ___________________________ DATE: ___________

IF CLIENT IS A MINOR, 17 YEARS OR YOUNGER, PLEASE CONTINUE BELOW:

PARENT/GUARDIAN’S NAME (PLEASE PRINT): ________________________________

PARENT/GUARDIAN’S SIGNATURE: _____________________________ DATE: __________