Who will follow this notice:

This notice describes the information privacy practices followed by our employees, staff and other office personnel. The practices described in this notice will also be followed by practitioners/providers you consult with by telephone (when your regular practitioner/provider from our office is not available) who provide “call coverage” for your practitioner/provider.

Your health information:

This notice applies to the information and records we have about your health, health status, and the health care and service you receive at this office. Your health information may include information created and received by this office, may be in the form of written or electronic records or spoken words, and may include information about your health history, health status, insurance claims history, utilization management decisions, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.

We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.

How we may use and disclose health information about you:

We may use and disclose health information for the following purposes:

• For Treatment. We may use health information about you to provide you with clinical treatment or services. We may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you and your health at our office.

• For Payment. We may use and disclose health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or a third party.

For example, we may need to give your health plan information about a service you received here so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will cover the treatment.

• For Health Care Operations. We may use and disclose health information about you in order to run the office and make sure that you and our other patients receive quality care.

For example, we may use your health information to evaluate the performance of our staff in caring for you. We may also use health information about all or many of our patients to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective.

• Appointment Reminders. We may contact you as a reminder that you have an appointment for treatment.

• Substance Abuse Treatment. Federal and State law require your written consent each time we release health information. The Consent will specify who is to receive the information, the purpose of the release of information, and a time period after which the Consent will terminate. You may modify or revoke Consent at any time. However, if we are unable to fulfill our requirements related to treatment, payment or health care operations, we may choose to discontinue providing you with health care treatment and services.

You may revoke your Consent at any time by giving us written notice. Your revocation will be effective when we receive it, but it will not apply to any uses and disclosures which occurred before that time. If you do revoke your Consent, we will not be permitted to use or disclose your information for purposes of treatment, payment or health care operations, and we may therefore choose to discontinue providing you with health care treatment and services.

Special situations:

We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:

• To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

• Required By Law. We will disclose health information about you when required to do so by federal, state or local law.

• Health Oversight Activities. We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.

• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.

• Law Enforcement. We may release health information if asked to do so by a law enforcement official in response to a court order.

• Information Not Personally Identifiable. We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

• Custodian of records. If my therapist is incapacitated, your health information will be in the custody of Jolene D, Nell, LCSW, LICSW. She will be the person who will be in charge to send your records to yourself or another health care provider at your request.

Other uses and disclosures of health information:

We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. We must obtain your Authorization separate from any Consent we may have obtained from you. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization (different than the Authorization) from you. In order to disclose these types of records for purposes of treatment, payment or health care operations, we will have to have both your signed Consent and a special written authorization that complies with the law governing HIV or substance abuse records.

Your rights regarding health information about you:

You have the following rights regarding health information we maintain about you:

• Right to Inspect and Copy. You have the right to inspect and copy your health information, such as clinical and billing records, that we use to make decisions about your care. You must submit a written request to office@horizononlinetherapy.com in order to inspect and/or copy your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies.

We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.

• Right to Amend. If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office.

To request an amendment, send an email to office@horizononlinetherapy.com. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

– We did not create, unless the person or entity that created the information is no longer available to make the amendment

– Is not part of the health information that we keep

– You would not be permitted to inspect and copy

– Is accurate and complete

– is needed to provide you emergency treatment.

To request restrictions, you may send an email to office@horizononlinetherapy.com.

• Right to Request Confidential Communications. You have the right to request that we communicate with you about clinical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

• Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of clinical information about you for purposes other than treatment, payment and health care operations.

To obtain this list, you must submit your request in writing to office@horizononlinetherapy.com. It must state a time period, which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time, before any costs are incurred.

• Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information

To request confidential communications, you may send an email to office@horizononlinetherapy.com. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

• Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy.

To obtain such a copy, send an email to office@horizononlinetherapy.com

Changes to this notice:

We reserve the right to change this notice, and to make the revised or changed notice effective for clinical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.

Complaints:

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, send an email to office@horizononlinetherapy.com. You will not be penalized for filing a complaint.

Effective date of this notice:

This notice went into effect on 11/04/2020.

Acknowledgement of Receipt of Privacy Notice:

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.