NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice went into effect on May 26th, 2026

ACKNOWLEDGEMENT OF RECIEPT 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.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Your counselor 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” 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 counselor.

• “Payment” is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to 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 this practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, case management and care coordination.

• “Use” applies only to activities within this clinic such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

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

II. Uses and Disclosures Requiring Authorization

Your counselor may use or disclose PHI for purposes outside of treatment, payment, or 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 the counselor is asked for information for purposes outside of treatment, payment or healthcare operations, he/she will obtain an authorization from you before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes your counselor has made about your conversations during a private, group, joint, or family counseling session, which have been 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 or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) the counselor or his/her representative has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

Your counselor may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse - If your counselor has reasonable cause to believe that a child has been abused, he/she must report that belief to the appropriate authority.

• Adult and Domestic Abuse - If your counselor has reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, he/she must report that belief to the appropriate authority.

• Health Oversight Activities - If your counselor is the subject of an inquiry by the Georgia Composite Board of Professional Counselors, Marriage & Family Therapists, and Social Workers, protected health information regarding you may be disclosed in proceedings before the Board.

• Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made about the professional services provided to you or the records thereof, such information is privileged for professional counselors under state law, and your information will not be released without your written consent or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

• Serious Threat to Health or Safety - If your counselor determines, or pursuant to the standards of his/her profession should determine, that you present a serious danger of violence to yourself or another, he/she may disclose information in order to provide protection against such danger for you or the intended victim.

• Worker’s Compensation - Your counselor may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

IV. Patient’s Rights and Counselor’s Duties

Patient’s Rights:

• Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information. However, your counselor is 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 a counselor. On your request, Johnson Psychotherapy and Consulting Services 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 the mental health and billing records used by your counselor to make decisions about you for as long as the PHI is maintained in the record. Your access to PHI may be denied under certain circumstances, but in some cases you may have this decision reviewed. On your request, your counselor or a designated agent of Johnson Psychotherapy and Consulting Services LLC 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 on the record. Your counselor or a designated agent may deny your request. On your request, your counselor or a designated agent will discuss with you the details of the amendment process.

• Right to Accounting - You generally have the right to receive an accounting of disclosures of PHI. On your request, your counselor or a designated agent 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 upon request, even if you have agreed to receive the notice electronically.

Duties:

• Johnson Psychotherapy and Consulting Services LLC is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.

• The administration of Johnson Psychotherapy and Consulting Services LLC reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, it is required that Johnson Psychotherapy and Consulting Services LLC abides by the terms currently in effect.

• If these policies and procedures are revised, you will be notified by mail at your last known address.

V. Complaints

If you are concerned your privacy rights may have been violated, or if you object to a decision Johnson Psychotherapy and Consulting Services LLC 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. Johnson Psychotherapy and Consulting Services LLC will provide you with the address. Under no circumstances will you be penalized or retaliated against for filing a complaint. Please discuss any questions or concerns with your therapist. Your signature on the “Information, Authorization, and Consent to Treatment” (provided to you separately) indicates that you have read and understood this document.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

Johnson Psychotherapy and Consulting Services LLC reserves the right to change the terms of this notice and make new notice provisions effective for all PHI that it maintains. You will be provided with a revised notice by electronic delivery and/or by your therapist.