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Health Insurance Portability and Accountability Act (HIPAA)

(Effective 10/1/2015)

I. COMMITMENT TO YOUR PRIVACY: TGIF Counseling, LLC / Michelle Panzarella, LCSW, MA (hereinafter "TGIF") is dedicated to maintaining the privacy of your protected health information (PHI). PHI is any information that may identify you and that relates to your past, present, or future physical & and/or mental health condition and related health care services. This Notice of Privacy Practices is required by law to provide you with information about the legal obligations and the privacy practices that TGIF maintains concerning your PHI. It also describes how medical and mental health information may be used and disclosed, as well as your rights regarding your PHI.

II. LEGAL DUTY TO SAFEGUARD YOUR PHI: By federal and state law, TGIF is required to ensure that your PHI is kept private. This notice explains the circumstances under which TGIF would use and/or disclose your PHI. Use of your PHI occurs when TGIF shares, apples, utilizes, examines, or analyzes information within its practice; PHI is disclosed when said therapist or agency releases, transfers, gives or otherwise reveals it to a third party. With some limited exceptions, TGIF may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, TGIF is always legally required to follow the privacy practices described in this Notice.

III. CHANGES TO THIS NOTICE: TGIF reserves the right to change the terms of this Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that TGIF maintains at that time. TGIF will provide you with a copy of the revised Notice of Privacy Practices at the appropriate time either in person or by mail. The date of the latest revision will always appear on the form.

• For Treatment. Your PHI may be used and disclosed by those who are involved in your care to provide, coordinate, or manage your healthcare treatment and related services. This includes consultation with clinical supervisors or other treatment team members. TGIF may disclose PHI to any other consultant only with your authorization.
• For Payment. TGIF may use and disclose PHI so that TGIF can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities include, but are not limited to: deciding on eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, TGIF will only disclose the minimum amount of PHI necessary for that collection activity.
• For Health Care Operations. TGIF may use or disclose, as needed, your PHI to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, TGIF may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided TGIF has a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes, PHI will be disclosed only with your authorization.
• Required by Law. Under the law, TGIF must disclose your PHI to you upon your request. In addition, TGIF must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

• Abuse or Neglect. TGIF may disclose your PHI to a state or local agency that is authorized by law to receive reports of child, elder, or dependent adult abuse or neglect. Example: If the therapist has a reasonable suspicion of child abuse or neglect, the therapist (as a mandated reporter) will report this to the Georgia Department of Child and Family Services.
• Judicial and Administrative Proceedings. TGIF may disclose your PHI pursuant to a subpoena, court order, administrative order or similar process.
• Deceased Patients. TGIF may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons who have been deceased for more than fifty (50) years is not protected under HIPAA.
• Medical Emergencies. TGIF may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. TGIF will try to provide you with a copy of this notice as soon as reasonably practicable after the resolution of the emergency.
• Family Involvement in Care. TGIF may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.
• Law Enforcement. TGIF may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena, court order, administrative order, or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or connection with a crime on the premises.
• Military and Veterans. TGIF may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons, and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.
• Public Health. If required, TGIF may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.
• Public Safety. TGIF may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person( or persons) reasonably able to prevent or lessen the threat, including the target of the threat.
• Health Oversight. If required, TGIF may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, or licensure of facilities. These activities are necessary for the government to monitor the health care system, government programs, and compliance with laws.
• Research. In certain limited circumstances, TGIF may use information you have provided for medical/psychological research, but only with your written authorization. PHI may only be disclosed after a special approval process OR with your authorization.

VI. OTHER USES AND DISCLOSURES REQUIRE YOUR PRIOR WRITTEN AUTHORIZATION: In any other situation not covered by this notice, the therapist will ask you for your written authorization only before using and/or disclosing any PHI about you. If you choose to authorize use or disclosure, you can later revoke that authorization by providing TGIF with written notice of that decision. You understand that TGIF is unable to take back any disclosures already made with your permission, will continue to comply with laws that require certain disclosures and is required to retain records of the care that any therapist has provided to you.

VII. YOUR RIGHTS REGARDING YOUR PHI: You have the following rights regarding your PHI that TGIF maintains about you. To exercise any of these rights, please submit your request in writing to Michelle Panzarella, LCSW, MA (address at top of this form)
• Right of Access to Inspect and Copy. You have the right (which may be restricted only in exceptional circumstances) to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. A request to have copies of such PHI must be done in writing and TGIF will respond within 30 days of receiving your written request. If you ask for copies of your PHI, you will be charged $ .25 per page for the copies and fees associated with supplies/postage. If your records are maintained electronically, you may also request an electronic copy of your PHI and these can be emailed to you through HUSH mail (a secure email server). You may also request that a copy of your PHI be provided to another person.
• Right to Amend. If you feel that the PHI that TGIF has about you is incorrect or incomplete, you may ask us to amend the information although TGIF is not required to agree to the amendment. If TGIF denies your request for amendment, you have the right to file a statement of disagreement with us. TGIF may prepare a rebuttal to your statement and will provide you with a copy. Please contact Michelle Panzarella, LCSW, MA if you have any questions.
• Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that TGIF make of your PHI. TGIF may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. TGIF are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, TGIF is required to honor your request for a restriction.
• Right to Request Confidential Communication. You have the right to request that TGIF communicate with you about health matters in a certain way or at a certain location. TGIF will accom
modate reasonable requests. TGIF may require information regarding how payment will be handled or the specification of an alternative address or other method of contact as a condition for accommodating your request. TGIF will not ask you for an explanation of why you are making the request.
• Breach Notification. If there is a breach of unsecured PHI concerning you, TGIF will notify you of this breach, including what happened and what you can do to protect yourself.
• Right to a Copy of this Notice.
You have the right to a copy of this notice by email or to request a paper copy of it.

VIII. COMPLAINTS: Complaints regarding your privacy rights or civil rights may be made directly to Michelle Panzarella, LCSW, M, c/o TGIF Counseling, LLC, 12579 Huntington Trace, Alpharetta, GA 30005. Or to 1) U.S. Health and Human Services Office of Civil Rights online at OR with the Department of Health and Human Services, Office of Civil Rights, at 200 Independence Avenue, S.W., Washington, D.C. 20201, Toll free numbers are: 1-800-368-1019 or TDD Toll-free 1-800-537-7697.

Your signature below indicates that you have read the Notice of Privacy Practices and agree to their terms.



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