We may use or disclose your protected health information (PHI), for treatment, payment, and health care

operations purposes with your consent. By acknowledging the receipt of this Notice, you are consenting to the use and disclosure of your PHI for treatment, payment, and health care operations. To help clarify these terms, here are some definitions:

“PHI” refers to information in your health record that could identify you.

“Use” applies only to activities within our agency such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

“Disclosure” applies to activities outside of our agency, such as releasing, transferring, or providing access to information about you to other parties.

“Treatment” – Treatment is when we provide, coordinate or manage your health care and other services related to your health care. For example, we may use and disclose your PHI when we consult with another health care provider, such as your family physician or another psychologist, about your treatment plan.

“Payment” is when we obtain reimbursement for your health care. For example, we may disclose your PHI to your health plan to obtain reimbursement for your health care or to determine your eligibility or coverage.

“Health Care Operations” are activities that relate to the performance and operation of our practice. For example, we use and disclose your PHI to assess and improve the quality of care and services we are providing to you, and we may share your PHI with our business associates, such as vendors who provide us with administrative services in order to operate our business.

“Business Associates” are vendors that handle PHI for us or on our behalf.

We may use or disclose PHI for purposes outside of treatment, payment, and health care operations with your valid authorization. An “authorization” is written permission above and beyond the general consent for treatment, payment, and health care operations. 

We are required to obtain a separate and specific authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your psychological record. These notes are given a greater degree of protection than PHI. In addition, we will obtain an authorization from you before releasing your PHI for any uses and disclosures not described in this Notice. You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing.

We will not use or disclose your PHI for marketing or sale purposes, unless you have signed an authorization. If you or your representative authorizes us to use or disclose your PHI, you may revoke that authorization in writing at any time to stop future uses or disclosures, except to the extent that action has already been taken in reliance on your authorization. Your revocation will not affect any use or disclosures permitted by your valid authorization while it was in effect. Your ability to get treatment, payment for treatment, and related services will not be conditioned on whether you authorize us to use or disclose your PHI for additional purposes.

We may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse: If, in our professional capacity, we know or suspect that a child under 18 years of age or an intellectually disabled, developmentally disabled, or physically impaired child under 21 years of age has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect, we are required by law to immediately report that knowledge or suspicion to the Ohio Public Children Services Agency, or a municipal or county peace officer.

Abuse, Neglect, or Domestic Violence: If we have reasonable cause to believe that an individual is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect, or exploitation, we are required by law to immediately report such belief to the County Department of Job and Family Services and other applicable government authorities.

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law and we will not release this information without written authorization from you or your personal or legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

Serious Threat to Health or Safety: We may use and disclose PHI about you as necessary to prevent or lessen a serious and imminent threat to the health or safety of yourself, another person, or the public.

Worker’s Compensation: If you file a worker’s compensation claim, we may be required to give your PHI to relevant parties and officials. We will only disclose records that are “psychotherapy notes” with your valid authorization.

Other: When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the HIPAA Privacy Rule and applicable state law. This includes certain narrowly defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

Your Rights and Providers’ Duties 

Your Rights:

Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of PHI about you. However, we are not required to agree to a restriction at your request.

Right to Restrict Disclosures When You or Someone Else Has Paid for Your Care – You have the right to restrict certain disclosures of PHI to a health plan if you or someone else has already paid in full for the health care service(s) you received.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing a therapist. Upon your request, we will send your bills to another address.)

Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, we will discuss with you the details of the request process.

Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in your record. We may deny your request. On your request, we will discuss with you the details of the amendment process.

Right to an Accounting – You generally have the right to receive an accounting of certain disclosures of PHI for which you have neither provided consent nor authorization. On your request, we will discuss with you the details of the accounting process.

Right to be Notified if There is a Breach of Your Unsecured PHI – You have the right to be notified if we (or our business associates) discover a breach involving your unsecured PHI.

Right to Receive a Copy of This Notice– You have the right to obtain a copy of this Notice from us upon request. 

Providers’ Duties:

We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. We reserve the right to change the privacy policies and practices described in this Notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. However, we will not use your previously collected PHI in a manner materially different than represented at the time it was collected without your consent or authorization, as applicable.

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about a request you submitted, you may file a grievance by contacting agency administrators at admin@animalcompanioncounseling.com

We support your right to privacy. You will not be retaliated against in any way if you choose to file a complaint. If you believe your rights have been violated and would like to submit a complaint directly to the U.S. Department of Health & Human Services, then you may submit a formal written complaint to the following address: 

U.S. Department of Health & Human Services Office for Civil Rights

200 Independence Avenue, S.W. Washington, D.C. 20201 

Call 1-877-696-6775 or visit www.hhs.gov/ocr/privacy/hipaa/complaints/