THIS NOTICE DESCRIBES POLICY ON FEDERAL REQUIREMENTS REGARDING CONFIDENTIALITY AND HOW MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW TO GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

Given the nature of our work, it is imperative that we maintain the confidence of client information that we receive in the course of treatment. Wells Counseling Services [or “WCS” hereafter], is a Christian mental health counseling center that treats individuals, couples, and families by providing individual, pre-marital, marital, family and group counseling. The practice works solely to provide the best counseling treatment options to its clients. WCS prohibits the release of any client information to anyone outside immediate staff, employees, and interns except in limited circumstances which are described below. Discussions or a disclosure of Protected Health Information (PHI) within the organization is limited to the minimum necessary that is needed for the recipient of the information to perform their duties.

This is your Health Information Privacy Notice from Wells Counseling Services. This notice describes how we protect the Personal Health Information we have about you which relates to you and how we may use and disclose this information. Personal Health Information includes individually identifiable information which relates to your past, present or future mental health, treatment or payment for health care services. This notice also describes your rights with respect to the Personal Health Information and how you can exercise those rights. The policy of WCS is as follows:

We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act (“HIPAA”). WCS is required to reasonably safeguard PHI from impermissible uses and disclosures. Seek legal counsel if you are uncertain of any situation and/or incident. Safeguard may include, but are not limited to the following:
• Fully comply with the requirements of the HIPAA General Administration Requirements and Privacy & Security Rules;
• Maintain the privacy of your Personal Health Information to avoid access by third parties;
• Provide every client who receives service a this notice of our legal duties and privacy practices with respect to your Personal Health Information;
• Exercising caution to protect client PHI and when speaking with a client about his or her PHI where third parties could possible overhear, counselor will move the conversation to a private area;
• Notify the client if WCS is unable to agree to a requested restriction;
• Ask the client to acknowledge receipt when given a copy of WCS Privacy Practices;
• Ensure the confidentiality of all client records transmitted by facsimile;
• Provide each client with the individual therapist’s Client Agreement and Authorization for use of PHI

In addition to complying with 12-43-218 CRS, WCS is required to follow all state statutes and regulations including Federal Regulation 42, C.F.R., Part 2 and Title 25, Article 4, Part 14 and Title 25, Article 1, Part 1, CRS, and the Health Insurance Portability and Accountability Act (HIPAA) 45 C.F.R. Parts 142, 160, 162, and 164, governing testing for and reporting of TB, HIV AIDS, Hepatitis, and other infectious diseases, (and maintain the confidentiality of PHI). These included exceptions are subject to several requirements under the Privacy Rule, including the minimum necessary requirements (you may only use and disclose the minimum amount of PHI necessary for the intended purpose of the use and/or disclosure). See 45 C.F.R. #164.512.

Before using or disclosing PHI for one of the above exceptions, consult WCS HIPAA Client Compliance Officer to ensure compliance with the Privacy Rule. Violation of these federal and state guidelines is a crime carrying both criminal and monetary penalties. Suspected violations may be reported to appropriate authorities in accordance with federal and state regulations.

Rev: 2016-01-25

PHI refers to any information that is created or received by WCS, and relates to an individual’s past, present or future physical or mental health conditions as well as related care services or the past present, or future payment for the provision of health care to an individual. PHI included any such information described below that WCS transmits or maintains. It includes any information that fulfills the following:
1. That identifies the individual; or
2. with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

We protect your Personal Health Information (PHI) from inappropriate use or disclosure.
“Use” applies only to activities within my office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

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

Our employees are required to comply with our requirements that protect the confidentiality of Personal Health Information. They may use your PHI ONLY when there is an appropriate reason to do so. A disclosure of PHI occurs when WCS reveals PHI to an outside party (i.e., WCS provides another treatment provider with PHI, or shares PHI with a third party pursuant to a client’s valid written authorization).

WCS may use and disclose PHI, without an individual’s written authorization, of the following purposes:
1. Treatment (including but limited to the provision and coordination of care)
2. Payment (including but limited to billing and claims management,).
3. Health Care Operations (including but not limited to general administrative activities of WCS, resolution of internal grievances or customer service)

Uses and disclosures for payment and health care operation purposes are subject to the minimum necessary requirements. This means that WCS may only use or disclose the minimum amount of PHI necessary for the purposes of the use of disclosure (i.e., billing purposes, WCS would not need to disclose a client’s entire medical record in order to receive reimbursement. WCS would likely only need to include a service code, etc.) Uses and disclosures for treatment purposes are not subject to the minimum necessary requirement.

Federal law and regulations protect the confidentiality of client records maintained by WCS. It is WCS policy that a client must complete an Authorization for use of disclosure of PHI (see attachment 1), provided by WCS, prior to disclosing health information for any purpose except for treatment, payment, or health care operations. We will not disclose your PHI to any other company for their use in marketing their products to you.

WCS is permitted and/or required to report or disclose your PHI if and when any of the following occur with WCS:

• Client consents in writing
• Use in client Payment: We may use and disclose PHI to pay for process your payment.
• For Health Care Operations: We may also use and disclose Personal Health Information at your request for your insurance needs.
• To Avert a Serious Threat to Health or Safety: We may disclose PHI to avert a serious threat to someone’s health or safety.
• Disclosure is made to medical personnel in a medical emergency or to a qualified personnel for research, audit or program evaluation
• Client commits or threatens to commit a crime either at the program or against any person who works for the program
• Minor or elderly client reports having been abused
• Client is planning to harm another person, including but not limited to the harm of a child
• Client reports suicidal ideation or self-harm
• Client reports sexual contact with counselor/therapist/minister
• Disclosure by court order
• For Law Enforcement or Specific Government Functions: We may disclose PHI in response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. We may disclose PHI about you to federal officials for intelligence, counterintelligence, and other national security activities authorized by law. we may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence and other national security activities.
• When Requested as a Part of a Regulatory or Legal Proceeding: If you or your estate are involved in a lawsuit, divorce or a dispute, we will release PHI at your request. Please note per your signed Informed Consent, you have agreed not to involve WCS Counselors in any current or future arbitration, mediation, and/or litigation within the court system. Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and we will not release the information without written authorization from you or your personal or legally-appointed representative, or a subpoena/court order. The privilege does not apply when you are being evaluated by a third party or where the evaluation is court ordered.

• Other Uses of Personal Health Information: Other uses and disclosures of PHI not covered by this notice and permitted by the laws that apply to us will be made only with your written authorization or that of your legal representative. If we are authorized to use or disclose PHI about you, you or your legally authorized representative may revoke that authorization, in writing, at any time, except to the extent that we have taken action relying on the authorization. We may use PHI to provide you with information about services that may be of interest to you. You should understand that we will not be able to take back any disclosures we have already made with authorization.

Cost of Processing PHI Request: In most cases, you have the right to inspect and obtain a copy of the Personal Health Information that we maintain about you. Due to the cost of preparing and transmitting requested PHI, we will charge $25 flat fee for up to 25 pages and an additional $1 per page thereafter.

Right to Amend Your Personal Health Information: If you believe that your PHI is incorrect or that an important part of it is missing, you have the right to ask us to amend your PHI while it is kept by or for us. We may deny your request if you ask us to amend PHI that:
• Is accurate and complete;
• Was not created by us, unless the person or entity that created the PHI is no longer available to make the amendment;
• Is not part of the PHI kept by or for us, or
• Is not part of the PHI which you would be permitted to inspect and copy.

Right to a List of Disclosures: Clients have the right to request a list of the disclosures we have made of Personal Health Information. This list will NOT include disclosures made for treatment, payment, health care operations, for purposes of national security, made to law enforcement or to corrections personnel, or made pursuant to the client’s authorization or made directly to the client. The client must state the time period from which is wanted to receive a list of disclosures. The time period may not be longer than six years and may not include dates before April 14, 2003.

Right to Request Restrictions: You have the right to request a restriction or limitation on PHI we use of disclose about you for treatment, payment or health care operations, or that we disclose to someone who may be involved in you care of payment for you care, like a family member or friend. While we will consider your request, we are not required to agree to it.

Right to Request Confidential Communications: You have the right to request that we communicate with you about PHI in a certain way or at a certain location if you tell us that communication in another manner may endanger you. For example, you can ask that we only contact you at work or by mail.

Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us. All complaints must be submitted in writing. Please also refer to the section on arbitration in the counselor’s informed consent.

Texas State Board of Examiners of Licensed Professional Counselors, Licensed Marriage and Family Therapists or Licensed Social Workers by writing to:
Complaints Management and Investigative Section
P.O. Box 141369 Austin, Texas 78714-1369
or
by calling 1.800.942.5540.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.
Office for Civil Rights
U.S. Department of Health & Human Services
150 S. Independence Mall West - Suite 372
Philadelphia, PA 19106-3499
(215) 861-4441; (215) 861-4440 (TDD) Fax: (215) 861-4431
You may also visit this web site for forms: http://www.hhs.gov/ocr/privacyhowtofile.htm

WCS respects the right to the privacy of its clients’ health information. There will be no retaliation in any way for filing a complaint with the U.S. Department of Health and Human Services.

Changes to This Notice: We reserve the right to change the terms of this notice at any time. We reserve the right to make the revised or changed notice effective for Personal Health Information we already have about you as well as any Personal Health Information we receive in the future.

Right to Obtain a Paper Copy of this Notice: You have the right to receive a paper copy of this notice and any amended notice upon request. Copies will be available at the reception desk in our counseling center. You may also obtain a copy of this notice at our web site.

I have read and understand my Rights to Privacy & Disclosure as outlined in this Notice. This form expires one year from date of signature.