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There are federal and state requirements that outline how your protected health information (PHI) should be handled. Following is a description of the requirements and how they are handled in our practice.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations Successful Pathways Behavioral Consulting, Inc. may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions: _“PHI” refers to information in your health record that could identify you. _“Treatment, Payment and Health Care Operations” – Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist. – Payment is when you or I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer so you can obtain reimbursement for your health care or to determine eligibility or coverage. – Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. _“Use” applies only to activities within Successful Pathways Behavioral Consulting such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. _“Disclosure” applies to activities outside of Successful Pathways Behavioral Consulting such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization Successful Pathways Behavioral Consulting may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain authorization before releasing your therapy notes. “Therapy notes” are notes we may have made about our work during individual or group sessions, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) We have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization Successful Pathways Behavioral Consulting may use or disclose PHI without your consent or
authorization in the following circumstances: Child Abuse: If you give us information that leads us to suspect child abuse, neglect, or death due to maltreatment, we must report such information to the county Department of Social Services. If asked by the Director of Social Services to turn over information from your records
relevant to a child protective services investigation, we must do so. Adult and domestic abuse: If the information you give us gives me reasonable cause to believe that a disabled adult is in need of protective services, we must report this to the Director of Social Services. Successful Pathways Behavioral Consulting does not participate in parent custody or legal manners unless the law states otherwise. _Serious Threat to Health or Safety:_ Successful Pathways Behavioral Consulting may disclose

IV. Patient's Rights _Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request. _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 us. 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 in my mental health and billing records (but not including therapy notes), used to make decisions about you for as long as the PHI is maintained in the record. You must submit your request in writing. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process. _Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Successful Pathways Behavioral Consulting 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 disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, we will discuss with you the details of the accounting process. _Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically or other means by which information is sent to you.

V. Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may file a complaint by writing to us at our office address. You may also send a written complaint to the Department of Health and Human Services. Office of Civil Rights (877) 696-6775 website

VI. Effective Date, Restrictions and Changes to Privacy Policy This notice will go into effect on April 1, 2022. Successful Pathways Behavioral Consulting reserves the right to change the privacy policies and practices described in this notice. If we revise our policies and procedures, we will post a copy of our current Notice in our office or on our website. You may request, and we will provide, a copy of our most current Notice at any time.

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