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

Family Dynamics Behavioral Health is committed to protecting your privacy. Family Dynamics Behavioral Health is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. Family Dynamics Behavioral Health is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains our legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

Tennessee licensing laws provide strong privileged communication protections for conversations between your clinician and you in the context of your established professional relationship with him/her. It should be noted that privileged communication is not the same as documentation. Documentation refers to the mental health written records that are kept about you and your care; such documentation is required by law, professional standards, and other review procedures.

The state of Tennessee requires the patient’s authorization and consent for treatment, payment, and healthcare operations. HIPAA does nothing to change this requirement by law in Tennessee. Your clinician may disclose PHI for the purposes of treatment, payment, and healthcare operations with your consent. You have signed this general consent to care and authorization to conduct payment and health care operations, authorizing your clinician to provide treatment and to conduct the administrative steps associated with your care (for example, file insurance for you) and to collaborate with your other providers regarding your care.

Sharing/Selling of information
• This office does not use your Protected Health Information (PHI) for fundraising or marketing. We will not sell your information.

LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communication between a patient and their mental health provider. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where we are permitted or required to disclose information without either your consent or authorization. If such a situation arises, we will limit our disclosure to what is necessary. Reasons we may have to release your information without authorization:

1. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if we receive a subpoena of which you have been properly notified and you have failed to inform us that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order us to disclose information.
2. If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, we may be required to provide it for them.
3. If a patient files a complaint or lawsuit against us, we may disclose relevant information regarding that patient in order to defend ourselves.
4. If a patient files a worker's compensation claim, and we are providing necessary treatment related to that claim, we must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier, or an authorized qualified rehabilitation provider.
5. We may disclose the minimum necessary health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

There are some situations in which we are legally obligated to take actions, in which we believe are necessary to attempt to protect others from harm, and we may have to reveal some information about a patient's treatment:

1. If we know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the State of Tennessee Abuse Hotline. Once such a report is filed, we may be required to provide additional information.
2. If we know or have reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the State of Tennessee Abuse Hotline. Once such a report is filed, we may be required to provide additional information.
3. If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, we may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.

CLIENT RIGHTS AND CLINICIAN DUTIES

Use and Disclosure of Protected Health Information:

● For Treatment – We use and disclose your health information internally in the course of your treatment. If you wish to provide information outside of our practice for your treatment by another health care provider, we will have you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
● For Payment – We may use and disclose your health information to obtain payment for services provided to you as delineated in the Consent for treatment.
● For Operations – We may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. We may also use your information to tell you about services, educational activities, and programs that we feel might be of interest to you.

Patient's Rights:
● Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
● Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree to such unless a law requires us to share that information.
● Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are 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.
● Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Furthermore, there is a copying fee charge of $1.00 per page. Please make your request well in advance and allow 2 weeks to receive the copies. If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request.
● Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and we will decide if it is and if we refuse to do so, we will tell you why within 60 days.
● Right to a Copy of This Notice – If you received the paperwork electronically, you may download a copy from your patient portal. If you completed this paperwork in the office at your first visit a copy will be provided to you per your request or at any time.
● Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, we will discuss with you the details of the accounting process.
● Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; we will make sure the person has this authority and can act for you before we take any action.
● Right to Choose – You have the right to decide not to receive services with us. If you wish, we will provide you with names of other qualified professionals.
● Right to Terminate – You have the right to terminate therapeutic services with us at any time without any legal or financial obligations other than those already accrued. We ask that you discuss your decision with us in session before terminating or at least contact us by phone letting us know you are terminating services.
● Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not we think releasing the information in question to that person or agency might be harmful to you.

Our Duties:
● We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law. We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. Should Family Dynamics Behavioral Health make changes, you may obtain a revised Notice by requesting a copy from Family Dynamics Behavioral Health or by viewing a copy on the website www.familydynamicsbh.com.

• Family Dynamics will inform you if PHI is compromised in a breach.

You may revoke your authorization, at any time, by contacting the Family Dynamics Behavioral Health in writing, using the information above. Family Dynamics Behavioral Health will not use or share PHI other than as described in Notice unless you give your permission in writing.


To file a complaint if you feel your rights are violated.

• You can file a complaint by contacting the Practice using the following information:

Jordan Haynes or Chenoa Shenandoah, practice owners
Family Dynamics Behavioral Health
318 N Forest Blvd
Knoxville TN, 37919
865-263-2200

• You can file a complaint with the State of Tennessee Department of Health or U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. the State of (ADD YOUR STATE HERE) Department of Health

• Family Dynamics Behavioral Health will not retaliate against you for filing a complaint.

AGREEMENT
I agree to and understand the provider’s use of protected health information as described in the notice for treatment, payment, or other health care operations. I understand that I must provide a separate
authorization before any disclosure may be made, except as otherwise specified

This Notice will go into effective on July 1, 2022, and remain so unless new notice provisions effective for all protected health information are enacted accordingly.