HIPAA Notice of Privacy Practices Form



    I. COMMITMENT TO YOUR PRIVACY: Breakthru Counseling & Consulting, P.C. (“BCC”) is dedicated
    to maintaining the privacy of your protected health information (PHI). PHI is information that may
    identify you and that relates to your past, present or future physical or mental health condition and
    related health care services either in paper or electronic format. This Notice of Privacy Practices
    (“Notice”) is required by law to provide you with the legal duties and the privacy practices that BCC
    maintains concerning your PHI. It also describes how medical and mental health information may be
    used and disclosed, as well as your rights regarding your PHI. Please read carefully and discuss any
    questions or concerns with your therapist.

    II. LEGAL DUTY TO SAFEGUARD YOUR PHI: By federal and state law, BCC is required to ensure that
    your PHI is kept private. This Notice explains when, why, and how BCC would use and/or disclose your
    PHI. Use of PHI means when BCC shares, applies, utilizes, examines, or analyzes information within its
    practice; PHI is disclosed when BCC releases, transfers, gives, or otherwise reveals it to a third party
    outside of BCC. With some exceptions, BCC may not use or disclose more of your PHI than is necessary
    to accomplish the purpose for which the use or disclosure is made; however, BCC is always legally
    required to follow the privacy practices described in this Notice.

    III. CHANGES TO THIS NOTICE: The terms of this notice apply to all records containing your PHI that
    are created or retained by BCC. Please note that BCC reserves the right to revise or amend this Notice
    of Privacy Practices. Any revision or amendment will be effective for all of your records that BCC has
    created or maintained in the past and for any of your records that BCC may create or maintain in the
    future. BCC will have a copy of the current Notice in the office in a visible location at all times, and you
    may request a copy of the most current Notice at any time. The date of the latest revision will always
    be listed at the end of BCC’s Notice of Privacy Practices.

    IV. HOW BCC MAY USE AND DISCLOSE YOUR PHI: BCC will not use or disclose your PHI without your
    written authorization, except as described in this Notice or as described in the “PSYCHOLOGIST- CLIENT
    SERVICES AGREEMENT” document (provided to you separately). Below you will find the different
    categories of possible uses and disclosures with some examples.

    1. For Treatment: BCC may disclose your PHI to physicians, psychiatrists, psychologists, and other
    licensed health care providers who provide you with health care services or are; otherwise involved in
    your care. Example: If you are also seeing a psychiatrist for medication management, BCC may disclose
    your PHI to her/him in order to coordinate your care. Except for in an emergency, BCC will always ask
    for your authorization in writing prior to any such consultation.

    2. For Health Care Operations: BCC may disclose your PHI to facilitate the efficient and correct
    operation of its practice, improve your care, and contact you when necessary. Example: We use health
    information about you to manage your treatment and services.

    3. To Obtain Payment for Treatment: BCC may use and disclose your PHI to bill and collect
    payment for the treatment and services BCC provided to you. Example: BCC might send your PHI to
    your insurance company or managed health care plan in order to get payment for the health care
    services that have been provided to you. BCC could also provide your PHI to billing companies, claims
    processing companies, and others that process health care claims for BCC’s office if either you or your
    insurance carrier are not able to stay current with your account. In this latter instance, BCC will always
    do its best to reconcile this with you first prior to involving any outside agency.

    4. Employees and Business Associates: There may be instances where services are provided to BCC
    by an employee or through contracts with third-party “business associates.” Whenever an employee or
    business associate arrangement involves the use or disclosure of your PHI, BCC will have a written
    contract that requires the employee or business associate to maintain the same high standards of
    safeguarding your privacy that is required of BCC.

    Note: This state and Federal law provides additional protection for certain types of health information,
    including alcohol or drug abuse, mental health and AIDS/HIV, and may limit whether and how BCC may
    disclose information about you to others.

    disclose your PHI without your consent or authorization for the following reasons:

    1. Law Enforcement: Subject to certain conditions, BCC may disclose your PHI when required by
    federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement.
    Example: BCC may make a disclosure to the appropriate officials when a law requires BCC to report
    information to government agencies, law enforcement personnel and/or in an administrative

    2. Lawsuits and Disputes: BCC may disclose information about you to respond to a court or
    administrative order or a search warrant. BCC may also disclose information if an arbitrator or
    arbitration panel compels disclosure, when arbitration is lawfully requested by either party,
    pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other
    provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel. BCC will
    only do this if efforts have been made to tell you about the request and you have been provided an
    opportunity to object or to obtain an appropriate court order protecting the information requested.

    3. Public Health Risks: BCC may disclose your PHI to public health or legal authorities charged with
    preventing or controlling disease, injury, disability, to report births and deaths, and to notify persons
    who may have been exposed to a disease or at risk for getting or spreading a disease or condition.

    4. Food and Drug Administration (FDA): BCC may disclose to the FDA, or persons under the jurisdiction
    of the FDA, PHI relative to adverse events with respect to drugs, foods, supplements, products and
    product defects, or post marketing surveillance information to enable product recalls, repairs, or

    5. Serious Threat to Health or Safety: BCC may disclose your PHI if you are in such mental or emotional
    condition as to be dangerous to yourself or the person or property of others, and if BCC determines
    in good faith that disclosure is necessary to prevent the threatened danger. Under these
    circumstances, BCC may provide PHI to law enforcement personnel or other persons able to prevent
    or mitigate such a serious threat to the health or safety of a person or the public.

    6. Minors: If you are a minor (under 18 years of age), BCC may be compelled to release certain types
    of information to your parents or guardian in accordance with applicable law.

    7. Abuse and Neglect: BCC may disclose PHI if mandated by Georgia child, elder, or dependent adult
    abuse and neglect reporting laws. Example: If BCC has a reasonable suspicion of child abuse or
    neglect, BCC will report this to the Georgia Department of Child and Family Services.

    8. Coroners, Medical Examiners, and Funeral Directors: BCC may release PHI about you to a coroner
    or medical examiner. This may be necessary, for example, to identify a deceased person, determine
    the cause of death or other duties as authorized by law. BCC may also disclose PHI to funeral
    directors, consistent with applicable law, to carry out their duties.

    9. Communications with Family, Friends, or Others: BCC may release your PHI to the person you
    named in your Durable Power of Attorney for Health Care (if you have one), to a friend or family
    member who is your personal representative (i.e., empowered under state or other law to make
    health-related decisions for you), or any other person you identify, relevant to that person’s
    involvement in your care or payment related to your care. In addition, BCC may disclose your PHI
    to an entity assisting in disaster relief efforts so that your family can be notified about your

    10. Military and Veterans: If you are a member of the armed forces, BCC may release PHI about you as
    required by military command authorities. BCC may also release PHI about foreign military
    personnel to the appropriate military authority.

    11. National Security, Protective Services for the President, and Intelligence Activities: BCC may release
    PHI about you to authorized federal officials so they may provide protection to the President, other
    authorized persons, or foreign heads of state, to conduct special investigations for intelligence,
    counterintelligence, and other national activities authorized by law.

    12. Correctional Institutions: If you are or become an inmate of a correctional institution, BCC may
    disclose PHI to the institution or its agents when necessary for your health or the health and safety
    of others

    13. For Research Purposes: In certain limited circumstances, BCC may use information you have
    provided for medical/psychological research, but only with your written authorization. The only
    circumstance where written authorization would not be required would be if the information you
    have provided could be completely disguised in such a manner that you could not be identified,
    directly or through any identifiers linked to you. The research would also need to be approved by
    an institutional review board that has examined the research proposal and ascertained that the
    established protocols have been met to ensure the privacy of your information.

    14. For Workers' Compensation Purposes: BCC may provide PHI in order to comply with Workers'
    Compensation or similar programs established by law.

    15. Appointment Reminders: BCC is permitted to contact you, without your prior authorization, to
    provide appointment reminders or information about alternative or other health-related benefits
    and services that you may need or that may be of interest to you.

    16. Health Oversight Activities: BCC may disclose health information to a health oversight agency for
    activities such as audits, investigations, inspections, or licensure of facilities. These activities are
    necessary for the government to monitor the health care system, government programs and
    compliance with laws. Example: When compelled by U.S. Secretary of Health and Human Services
    to investigate or assess BCC’s compliance with HIPAA regulations.

    17. If Disclosure is Otherwise Specifically Required by Law.

    VI. Other Uses and Disclosures Require Your Prior Written Authorization: In any other situation not
    covered by this notice, BCC will ask for your written authorization before using or disclosing
    medical information about you. If you choose to authorize use or disclosure, you can later revoke
    that authorization by notifying BCC in writing of your decision. You understand that BCC is unable
    to take back any disclosures it has already made with your permission, BCC will continue to comply
    with laws that require certain disclosures, and BCC is required, as directed by law, to retain records
    of the care that its therapists have provided to you.


    1. The Right to See and Get Copies of Your PHI either in paper or electronic format: In general, you
    have the right to see your PHI that is in BCC’s possession, or to get copies of it; however, you must
    request it in writing. If BCC does not have your PHI, but knows who does, you will be advised how you
    can get it. You will receive a response from BCC within 30 days of receiving your written request. Under
    certain circumstances, BCC may feel it must deny your request, but if it does, BCC will give you, in
    writing, the reasons for the denial. BCC will also explain your right to have its denial reviewed. If you
    ask for copies of your PHI, you will be charged a reasonable fee per page and the fees associated with
    supplies and postage. BCC may see fit to provide you with a summary or explanation of the PHI, but
    only if you agree to it, as well as to the cost, in advance.

    2. The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to ask that
    BCC limit how it uses and discloses your PHI. While BCC will consider your request, it is not legally bound
    to agree. If BCC does agree to your request, it will put those limits in writing and abide by them except
    in emergency situations. If you pay for a service or health care item out-of-pocket in full, you can ask us
    not to share that information for the purpose of payment or our operations with your health insurer.
    You do not have the right to limit the uses and disclosures that BCC is legally required or permitted to

    3. The Right to Choose How BCC Sends Your PHI to You: It is your right to ask that your PHI be sent
    to you at an alternate address (for example, sending information to your work address rather than your
    home address) or by an alternate method (for example, via email instead of by regular mail). BCC is
    obliged to agree to your request providing that it can give you the PHI, in the format you requested,
    without undue inconvenience.

    4. The Right to Get a List of the Disclosures. You are entitled to a list of disclosures of your PHI that
    BCC has made. The list will not include uses or disclosures to which you have specifically authorized
    (i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family;
    neither will the list include disclosures made for national security purposes, or to corrections or law
    enforcement personnel. The request must be in writing and state the time period desired for the
    accounting, which must be less than a 6-year period and starting after April 14, 2003.
    BCC will respond to your request for an accounting of disclosures within 60 days of receiving your
    request. The list will include the date of the disclosure, the recipient of the disclosure (including address,
    if known), a description of the information disclosed, and the reason for the disclosure. BCC will provide
    the list to you at no cost, unless you make more than one request in the same year, in which case it will
    charge you a reasonable sum based on a set fee for each additional request.

    5. The Right to Choose Someone to Act for You: If you have given someone medical power of
    attorney or if someone is your legal guardian, that person can exercise your rights and make choices
    about your health information. We will make sure the person has this authority and can act for you
    before we take any action.

    6. The Right to Amend Your PHI: If you believe that there is some error in your PHI or that
    important information has been omitted, it is your right to request that BCC correct the existing
    information or add the missing information. Your request and the reason for the request must be made
    in writing. You will receive a response within 60 days of BCC’s receipt of your request. BCC may deny
    your request, in writing, if it finds that the PHI is: (a) correct and complete, (b) forbidden to be disclosed,
    (c) not part of its records, or (d) written by someone other than BCC. Denial must be in writing and must
    state the reasons for the denial. It must also explain your right to file a written statement objecting to
    the denial. If you do not file a written objection, you still have the right to ask that your request and
    BCC’s denial will be attached to any future disclosures of your PHI. If BCC approves your request, it will
    make the change(s) to your PHI. Additionally, BCC will tell you that the changes have been made and
    will advise all others who need to know about the change(s) to your PHI.

    7. The Right to Get This Notice by Email: You have the right to get this notice by email. You have
    the right to request a paper copy of it as well.

    8. Submit all Written Requests: Submit to BCC’s Director and Privacy Officer, Dr. Warner, at the
    address listed on top of page one of this document.

    VIII. COMPLAINTS: If you are concerned your privacy rights may have been violated, or if you object
    to a decision BCC made about access to your PHI, you are entitled to file a complaint. You may
    also send a written complaint to the Secretary of the Department of Health and Human Services
    Office of Civil Rights. BCC will provide you with the address. Under no circumstances will you be
    penalized or retaliated against for filing a complaint.

    IX. BCC’s Responsibilities: We are required by law to maintain the privacy and security of your PHI.
    We will let you know promptly if a breach occurs that may have compromised the privacy or
    security of your information. We must follow the duties and privacy practices described in this
    notice and give you a copy of it. We will not use or share your information other than as described
    here unless you tell us we can in writing. If you tell us we can, you may change your mind at any
    time. Let us know in writing if you change your mind.

    Please discuss any questions or concerns with your therapist.
    Your signature below indicates that you have read and understood this document.
    I voluntarily choose and ask that my typed name on the signature line(s) of this
    document legally represent my electronic signature.

    If applicable: