Notice of Policies and Practices to Protect the Privacy of Your Health Information

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

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
We (the clinical, leadership, and administrative teams at Seasons Counseling
Services) may use or disclose your protected health information (PHI), for
treatment, payment, and health care operations purposes in most instances
without your consent under HIPAA, but we will obtain consent in another form for
disclosing PHI for other reasons, including disclosing PHI outside of this practice,
except as otherwise outlined in this Policy. In all instances we will only disclose the
minimum necessary information in order to accomplish the intended purpose. To
help clarify these terms, here are some definitions:

• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment and Health Care Operations”

– Treatment is when we provide, coordinate or manage your health care and
other services related to your health care. An example of treatment would be
when we consult with another health care provider, such as your family
physician or another therapist.

- Payment is when we obtain reimbursement for your healthcare. Examples
of payment are when we disclose your PHI to your health insurer to obtain
reimbursement for your health care or to determine eligibility or coverage,
which would include an audit.

- Health Care Operations are activities that relate to the performance and
operation of our practice. Examples of health care operations are quality
assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care
coordination. 

• “Use” applies only to activities within our practice group, such as sharing,
employing, applying, utilizing, examining, and analyzing information that
identifies you.
• “Disclosure” applies to activities outside of our practice group, such as releasing,
transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes outside of treatment, payment, and
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 we are asked for
information for purposes outside of treatment, payment and health care
operations, we will obtain an authorization from you before releasing this
information, including uses and disclosures of PHI for marketing purposes, and
disclosures that constitute a sale of PHI. Examples of disclosures requiring an
authorization include disclosures to your partner, your spouse, your children and
your legal counsel. Any disclosure involving psychotherapy notes, if any of us
maintain them, will require your signed authorization, unless we are otherwise
allowed or required by law to release them. You may revoke an authorization for
future disclosures, but this will not be effective for past disclosures which you have
authorized.

III. Uses and Disclosures Requiring Neither Consent nor Authorization

We may use or disclose PHI without your consent or authorization as allowed by
law, including under the following circumstances:

• Serious Threat to Health or Safety: If we believe that you pose a clear and
substantial risk of imminent serious harm, or a clear and present danger, to
yourself or another person we may disclose your relevant confidential
information to public authorities, the potential victim, other professionals,
and/or your family in order to protect against such harm. If you communicate
to us an explicit threat of inflicting imminent and serious physical harm or
causing the death of one or more clearly identifiable victims, and we believe you
have the intent and ability to carry out the threat, then we may take one or
more of the following actions in a timely manner: 1) take steps to hospitalize you
on an emergency basis, 2) establish and undertake a treatment plan calculated
to eliminate the possibility that you will carry out the threat, and initiate
arrangements for a second opinion risk assessment with another mental health professional, 3) communicate to a law enforcement agency and, if feasible, to
the potential victim(s), or victim's parent or guardian if a minor, all of the
following information: a) the nature of the threat, b) your identity, and c) the
identity of the potential victim(s). We will inform you about these notices and
obtain your written consent, if we deem it appropriate under the circumstances.

• Worker’s Compensation: If you file a worker’s compensation claim, we may be
  required to give your mental health information to relevant parties and officials.

• Felony Reporting: We may be required or allowed to report any felony that you
  report to us that has been or is being committed.

• For Health Oversight Activities: We may use and disclose PHI if a government
  agency is requesting the information for health oversight activities. Some
  examples could be audits, investigations, or licensure and disciplinary activities
  conducted by agencies required by law to take specified actions to monitor
  health care providers, or reporting information to control disease, injury or
  disability.

• For Specific Governmental Functions: We may disclose PHI of military
  personnel and veterans in certain situations, to correctional facilities in certain
  situations, and for national security reasons, such as for protection of the
  President.
  • For Lawsuits and Other Legal Proceedings: If you are involved in a court
  proceeding and a request is made for information concerning your evaluation,
  diagnosis or treatment, such information is protected by law. We cannot provide
  any information without your (or your personal or legal representative’s) written
  authorization, or a court order. If you are involved in or contemplating litigation,
  you should consult with your attorney to determine whether a court would be
  likely to order us to disclose information. If a patient files a complaint or lawsuit
  against us, we may disclose relevant information regarding that patient in order
  to defend ourselves.
  • Abuse, Neglect, and Domestic Violence: If we know or have reason to suspect
  that a child under 18 years of age or a developmentally disabled or physically
  impaired child under 21 years of age has suffered or faces a threat of suffering
  any physical or mental wound, injury, disability, or condition of a nature that
  reasonably indicates abuse or neglect of the child or developmentally disabled
  individual under 21, the law requires that we file a report with the appropriate
  government agency, usually the County Children Services Agency. Once such a
  report is filed, we may be required to provide additional information. If we have
  reasonable cause to believe that a developmentally disabled adult, or an elderly
  adult in an independent living setting or in a nursing home is being abused,
  neglected, or exploited, the law requires that we report such belief to the
  appropriate governmental agency. Once such a report is filed, we may be
  required to provide additional information. If we know or have reasonable cause
  to believe that a patient or client has been the victim of domestic violence, we must note that knowledge or belief and the basis for it in the patient’s or client records. 

  • To Coroners and Medical Examiners: We may disclose PHI to coroners and
  medical examiners to assist in the identification of a deceased person and to
  determine a cause of death.
  • For Law Enforcement: We may release health information if asked to do so by
  a law enforcement official in response to a court order, subpoena, warrant,
  summons or similar process, subject to all applicable legal requirements.
  • Required by Law. We will disclose health information about you when required
  to do so by federal, state or local law.
  • Public Health Risks. We may disclose health information about you for public
  health reasons in order to prevent or control disease, injury or disability; or
  report births, deaths, non-accidental physical injuries, reactions to medications
  or problems with products.
  • 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.
  • SUD Treatment Information. If we receive or maintain any information about
  you from a substance use disorder treatment program that is covered by 42 CFR Part 2 (a “Part 2 Program”) through a general consent you provide to the Part 2
  Program to use and disclose the Part 2 Program record for purposes of
  treatment, payment or health care operations, we may use and disclose your
  Part 2 Program record for treatment, payment and health care operations
  purposes as described in this Notice. If we receive or maintain your Part 2
  Program record through specific consent you provide to us or another third
  party, we will use and disclose your Part 2 Program record only as expressly
  permitted by you in your consent as provided to us.
  • In no event will we use or disclose your Part 2 Program record, or testimony that describes the information contained in your Part 2 Program record, in any civil, criminal, administrative, or legislative proceedings by any Federal, State, or local authority, against you, unless authorized by your consent or the order of a court after it provides you notice of the court order.
  Other uses and disclosures will require your signed authorization, unless the use or disclosure is allowed or required by law. Once information is disclosed it may be redisclosed by the recipient and will no longer be protected by law.
• Other uses and disclosures will require your signed authorization.

IV. Patient's Rights and Our Duties Patient's Rights:

Right to Request Restrictions and Disclosures–You have the right to request
restrictions on certain uses and disclosures of protected health information
about you for treatment, payment or health care operations. However, we
are not required to agree to a restriction you request, except under certain
limited circumstances, and will notify you if that is the case. One right that we
may not deny is your right to request that no information be sent to your
health care plan if payment in full is made for the health care service. If you
select this option then you must request it ahead of time and payment must
be received in full each time a service is going to be provided. We will then
not send any information to the health care plan for that session unless we
are required by law to release this information.

• 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. If your request is reasonable, then we will honor it.
  

• Right to Inspect and Copy - You have the right to inspect or obtain a copy (or
  both) of PHI in our mental health and billing records used to make decisions
  about you for as long as the PHI is maintained in the record, except under
  some limited circumstances. If we maintain the information in an electronic
  format you may obtain it in that format. This does not apply to information
  created for use in a civil, criminal or administrative action or proceeding. We
  may charge you reasonable amounts for copies, mailing or associated
  supplies under most circumstances. We may deny your request to inspect
  and/or copy your record or parts of your record in certain limited
  circumstances. If you are denied copies of or access to your PHI, you may
  ask that our denial be reviewed.

• Right to Amend - You have the right to request an amendment of PHI for as
  long as the PHI is maintained in the record. We may deny your request, but
  will note that you made the request. Upon your request, we will discuss with
  you the details of the amendment process.

• Right to an Accounting - With certain exceptions, you generally have the
  right to receive an accounting of disclosures of PHI, not including disclosures
  for treatment, payment or health care operations, for paper records on file
  for the past six years and for an accounting of disclosures made involving
  electronic records, including disclosures for treatment, payment or health
  care operations, for a period of three years. On your request we 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 from us upon request, even if you have agreed to receive the notice
  electronically.
  

  Our Duties :

• • We are required by law to maintain the privacy of PHI, to provide you with
  this notice of our legal duties and privacy practices with respect to PHI, and
  to abide by the terms of this notice.
  • We reserve the right to change the privacy policies and practices described in
  this notice and to make those changes effective for all of the PHI we
  maintain.
  • If we revise our policies and procedures, which we reserve the right to do, we
  will make available a copy of the revised notice to you on our website, if we
  maintain one, and one will always be available at our office. You can always
  request that a paper copy be sent to you by mail.
  • In the event that we learn that there has been an impermissible use or
  disclosure of your unsecured PHI, unless there is a low risk that your
  unsecured PHI has been compromised, we will notify you of this breach.

V. Complaints and Effective Date

If you are concerned that we have violated your privacy rights, or you disagree with
a decision we make about access to your records, you may file a complaint with us
and we’ll consider how best to resolve your complaint. Contact our Privacy Officer,
listed below, if you wish to file a complaint with us. In the event that you aren’t
satisfied with our response to your complaint, or don’t want to first file a complaint
with us, then you may send a written complaint to the Secretary of the U.S.
Department of Health and Human Services inin Washington, D.C., 200 Independence Avenue S.W., Washington, D.C. 20201, Ph: 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/compliants/

There will be no retaliation against you for filing a complaint. This notice is effective as of August 1, 2026. 

VII. Privacy and Security Officer The Privacy and Security Officer for Seasons is your Seasons therapist. You may contact them if you have any questions about any Privacy or Security Policies or if you wish to file a complaint with the practice. You are also always welcome to reach out to the practice owner, Dr. Andy Erkis: andy@seasonscounselingservices.com,
614-706-2228 x 3 

 

ACKNOWLEDGEMENT OF RECEIPT OF SEASONS NOTICE OF PRIVACY PRACTICES

By signing this document, I acknowledge that I have received a copy of Season’s
Notice of Privacy Practices. I also acknowledge that I have had a chance to ask
questions about it.

OR GUARDIAN/PERSONAL REPRESENTATIVE

(Has Legal Authority over Health Care of Resident)