Restoration Counseling of Atlanta, LLC
595 Colonial Park Drive
Suite 102
Roswell, GA 30075

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Notice of Privacy Practice

Privacy is a very important concern for all those who come to Restoration Counseling of Atlanta. It is a complicated issue because of federal and state laws and our professional ethics. If you have any further questions after reading this disclosure please feel free to contact our offices Privacy Officer listed at the end of this document.

Contents of this Notice

1. Introduction – To our clients
2. What we mean by your medical information
3. Privacy and the laws about privacy
4. How your protected health information can be used and shared
   1. Uses and disclosures with your consent
      1. The basic uses and disclosures – For treatment, payment, and health care operations (TPO)
      2. Other uses and disclosures in health care
   2. Uses and disclosures requiring your Authorization
   3. Uses and disclosures not requiring your Consent or Authorization
   4. Uses and disclosures requiring you have an opportunity to object.
   5. An Accounting of disclosures we have made
5. If you have questions or problems

A. Introduction – To our clients

This notice will tell you about how we handle information about you. It tells how we use this information here in this office, how we share it with other professionals and organizations, and how you can see it. We want you to know all of this so that you can make the best decisions for yourself and your family. We are also required to tell you about this because of the privacy regulations of a federal law called the Health Insurance Portability and Accounting Act of 1996 (HIPAA). Because of this law, the laws of this state are very complicated and we do not want to make you read information that may not apply to you, we have simplified some parts and provided the necessary information. If you have any questions or want to know more about anything in this Notice, please ask our Privacy Officer for more explanation or more details.

B. What we mean by your medical information

Each time you visit a doctor’s office, hospital, clinic, or any other “healthcare provider” information is collected about you and your physical and mental health. It may be information about your past, present or future health or conditions, or the treatment or other services you got from us or from others, or about payment for healthcare. The information we collect from you is called, in the law, PHI, which stands for Protected Health Information. This information goes into your medical or healthcare record or file at our office. In this office this PHI is likely to include these kinds of information:

• Your history - As a child, in school and at work, and marital and personal history.
• Reasons you came for treatment - Your problems, complaints, symptoms, needs and goals
• Diagnosis - Diagnoses are the medical terms for your problems or symptoms.
• A treatment plan - These are the treatments and other services which we think will best help you.
• Progress notes - Each time you come in we write down some things about you, how you are doing, what we observe about you and what you tell us.
• Records we get from others who treated you or evaluated you.
• Psychological tests scores, school records, etc.
• Information about medications you took or are taking.
• Legal matters
• Billing and Insurance information

This list is just to give you an idea. There may be other kinds of information that go into your healthcare record here. We use this information for many purposes. For example, we may use it:

• To plan your care and treatment.
• To decide how well our treatments are working for you.
• When we talk with other healthcare professionals who are also treating you such as your family doctor.
• To show that you actually received the services from us that we billed to you or to your health insurance company.
• For teaching and training other healthcare professionals.
• For medial or psychological research.
• For public health officials trying to improve health care in this country.
• To improve the way we do our job by measuring the results of our work.

When we understand what is in your record and what it is used for, you can make better decisions about whom, when, and why other should have this information.

Although your health record is the physical property of the healthcare practitioner or facility that collected it, the information belongs to you. You can inspect, read, or review it. If you want a copy we can make one for you but we may charge you for the costs of copying (and mailing if you want it mailed to you). In some very unusual situations you cannot see all of what is in your records. If you find anything in your records that you think is incorrect or something important is missing, you can ask us to amend (add information to) your record, although in some rare situations we don’t have to agree to do that. Our Privacy Officer, whose name is at the end of this notice, can explain more about that.

C. Privacy and the laws about privacy

The HIPAA requires us to keep your PHI private and to give you this notice of our legal duties and our privacy practices, which is called the Notification of Practices or NPP. We will obey the rules of this notice as long as it is in effect, but if we change it the rules of the new NPP will apply to all the PHI we keep. If we change the NPP, we will post the new Notice in our office where everyone can see it. You or anyone else can also get a copy from our Privacy Officer at any time and it will be posted on our website at www.restorationcounselingatl.com.

D. How your protected health information can be used and shared

When your information is read by me or others in this office that is called, in the law, “use.” If the information is shared with or sent to others outside of this office, that is called, in the law, “disclosure.” Except in some special circumstances, when we use your PHI here or disclose it to others we share only the minimum necessary PHI needed for the purpose. The law gives you rights to know about your PHI, to know how it is used and to have a say in how it is disclosed, and so we will tell you more about what we do with your information.

We use and disclose PHI for several reasons. Mainly, we will use and disclose (share) it for routine purposes, and we will explain more about these below. For other uses we must tell you about them and have a written Authorization from you unless the law lets or requires us to make the use or disclosure without your authorization. However, the law also says that we are allowed to make some uses and disclosures without your consent or authorization.

1. Uses and disclosures of PHI in healthcare with your consent

After you have read this Notice you will be asked to sign a separate Consent form to allow us to use and share your PHI. In almost all cases we intend to use your PHI here or share your PHI with other people or organizations to provide treatment to you, arrange for payment for our services, or some other business functions called health care operations. Together these routine purposes are called TPO. The Consent form allows us to use and disclose your PHI for TPO except in cases pertaining to treatment where we must release your PHI to any other person outside this office. In that case we must have you sign and Authorization for release of PHI.

a. For treatment, payment, or health care operations

We receive information about you and your condition to provide care to you. You have to agree to let us collect the information and to use it and share it as necessary to care for you properly. Therefore, you must sign the Consent form before we begin to treat you because if you do not agree and consent, we cannot treat you.

When you come to see us, several people in our office may collect information about you and all of it may go into your healthcare records here. Generally, we may use or disclose your PHI for three purposes: treatment, obtaining payment, and what are called healthcare operations.

For treatment

We use your medical information to provide you with psychological treatment or services. These include individual, family, or group therapy, psychological, educational, or vocational testing, treatment planning, or measuring the effects of our services.

In the state of Georgia, we may share or disclose your PHI to others who provide treatment to you only if we obtain an Authorization from you in order to do this. We may want to share information about you with your personal physician. If you are being treated by a team, we can share some of your PHI with them so that the services you received are coordinated. They will also enter their findings, the actions they took, and their plans into your record and so we can all decide what treatments work best for you and make up a Treatment Plan. We may refer you to other professionals or consultants for services we cannot offer such as a special testing or treatments. When we do this we need to tell them some things about you and your conditions. We will get back their findings and opinions and those will go into you records here. These are some examples so that you can see how we use and disclose your PHI for treatment.

For some clients who chose to utilize their benefits through a managed care organizations (MCO) which requires treatment authorization, we will have to fill out treatment plans for you. If your insurance company requires treatment authorizations, you must sign the Consent form that allows us to give this information about you. These treatment plans include symptoms, diagnoses, treatment methods utilized, treatment goals and progress toward those goals. If you do not want us to release this information to the insurance company, please let us know. If you are unsure about this, please talk to your therapist.

For payment

We may use your information to bill you, your insurance, or others to be paid for the treatment we provide to you. We may contact your insurance company to check on exactly what your insurance covers. We may have to tell them about your diagnoses, what treatments you have received, and what we expect as we treat you. We will need to tell them about when we met, your progress, and other similar things.

For health care operations

There are some other ways we may use or disclose your PHI, which are called health care operations. For example, we may use your PHI to see where we can make improvements in the care and services we provide. We may be required to supply some information to some government health agencies so they can study disorders and treatment and make plans for services that are needed. If we do, your name and identity will be removed from what we send.

b. Other uses in healthcare

Appointment Reminders - We may use and disclose medical information to reschedule or remind you of appointments for treatment or other care. If you want us to call or write to you only at your home or your work or prefer some other way to reach you, we usually can arrange that. Just tell us.

Treatment Alternatives - We may use and disclose your PHI to tell you about or recommend possible treatments or alternatives that may be of interest to you.

Research - In rare cases, we may use or share your information to do research to improve treatments. For example, comparing two treatments for the same disorder to see which works better or faster or costs less. In all cases your name, address and other information that reveals who you are will be removed from the information given to researchers. If they need to know who you are we will discuss the research project with you and you will have to sign a special Authorization form before any information is shared.

Business Associates - There are some jobs we hire other businesses to do for us. These are called our Business Associates in the law. Examples include our accountant who may see your name posted in our financial records. These type business associates need to receive some of your PHI to do their jobs properly. To protect your privacy they have agreed in their contract with us to safeguard your information.

2. Uses and disclosures requiring your Authorization

If we want to use your information for any purposes besides the TPO or those we described above we need your permission on an Authorization form. According to Georgia law, we actually have to obtain your authorization for treatment purposes with other professionals. In this office, an Authorization form will be obtained any time we need to discuss or release PHI about you to another person outside our staff.

If you are involved in a lawsuit or legal proceeding and we receive a subpoena, discovery request, or other lawful process, we will assert the therapist-patient privilege to protect your confidentiality.

If you do authorize us to use or disclose your PHI, you can revoke (cancel) that permission, in writing, at any time. After that time we will not use or disclose your information for the purposes that we agreed to. Of course, we cannot take back any information we had already disclosed with your permission or that we had used in our office.

3. Uses and disclosures of PHI from mental health records not requiring Consent or Authorization.

The law lets us use and disclose some of your PHI without your consent or authorization in some cases.

When required by law

There are some federal, state, or local laws that require us to disclose PHI.
We have to report suspected child abuse.
We have to release (disclose) some information to the government agencies which check on us to see that we are obeying the privacy laws.

For specific government functions

We may disclose PHI of military personnel and veterans to government benefit programs relating to eligibility and enrollment, to Workers’ Compensation programs, to correctional facilities if you are an inmate, or for national security reasons.

To Prevent a Serious Threat to Health or Safety

If we come to believe that there is a serious threat to your health or safety or that of another person or public we can disclose some of your PHI. We will only do this to persons who can prevent the danger.

4. Uses and disclosures requiring you have an opportunity to object.

5. An Accounting of disclosures we have made

When we disclose your PHI we keep some records of whom we sent it, when we sent it, and what we sent. You can get an accounting (a list) of these disclosures.

E. If you have questions or problems

If you need more information or have questions about the privacy practices described above, please speak to the Privacy Officer whose name and telephone number are listed below. If you have a problem with how your PHI has been handled or if you believe your privacy rights have been violated, contact the Privacy Officer. You have the right to file a complaint with us and with the Secretary of the Federal Department of Health and Human Services. We promise that we will not in any way limit your care here or take any actions against you if you complain.

If you have any questions regarding this notice of our health information privacy practices, please contact our Privacy Officer who is Jennifer Stuckert and can be reached at 678.534.3824.

The effective date of this notice is September 26, 2009.