Effective Date of this Notice and Policy: August 1st, 2013

PURPOSE: Marriage and Family Services, Inc. and its professional staff, employees, and trainees follow the privacy practices described in this Notice. Marriage and Family Services, Inc. keeps your mental health information in records that will be maintained and protected in a confidential manner, as required by law. Please note that in order to provide you with the best possible care and treatment all professional staff involved in your treatment and employees involved in the health care operations of the agency may have access to your records. Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules.

Your treatment includes sharing information among mental health care providers who are involved in your mental health care services. For example, if you have a release on record, a psychotherapist may share information with your physician or other healthcare provider, in the process of coordinating your care. Treatment records may be reviewed as part of on-going process directed toward assuring the quality of Agency operations. Staff members designated by the Quality Improvement Committee may access clinical records periodically to verify that Agency standards are met.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment. Your personal record will be retained by Marriage and Family Services, Inc. for approximately seven (7) years after your last clinical contact. After that time has elapsed, your practice records will be erased, shredded, burned or otherwise destroyed in a way that protects your privacy. Copies of service records that have been distributed to other entities may continue to exist and managed by their policies. Until the records are destroyed they may be used for the following purposes unless you request restrictions on a specific use or disclosure:

Appointment reminders and notification when an appointment is cancelled or rescheduled;

For public health purposes such as reporting of child or elder abuse or neglect; reporting reactions to medications; infectious disease control; notifying authorities of suspected abuse, neglect, or domestic violence (if you agree or as required by law);

Mental health oversight activities, e.g., audits, inspections or investigations of administration and
management of Marriage and Family Services, Inc.;

Lawsuits and disputes;

Law enforcement (e.g., in response to a court order or other legal process) to identify or locate an individual being sought by authorities; about a victim of a crime under restricted circumstances; about a death that may be the result of criminal conduct; about criminal conduct that occurred in the practice; when emergency circumstances occur relating to a crime;

To prevent a serious threat to health or safety;

To carry out mental health services and through transcription and billing services;

Specialized government functions (e.g., to military command authorities if you are a member of the armed forces or a member of a foreign military authority; national security and intelligence activities; protection of the President or other authorized persons for foreign heads of state, or to conduct special investigations.

Psychotherapy notes that are kept separate from the record enjoy special protection and require
authorization for release, with certain exceptions.

Psychotherapy notes excludes counseling session start and stop times, the results of clinical tests, and any summary of the following items: diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information.

Alcohol and drug abuse information has special privacy protections. Marriage and Family Services, Inc. will not disclose any information identifying an individual as being a client or provide any mental health or medical information relating to a client¹s substance abuse/mental health services unless: (i) the client consents in writing; (ii) a court order requires disclosure of the information; (iii) medical personnel need the information to meet a medical emergency; (iv) qualified personnel use the information for the purpose of conducting research, management audits, or program evaluation; or (v) it is necessary to report a crime or a threat to commit a crime or to report abuse or neglect as required by law.

YOUR AUTHORIZATION IS REQUIRED FOR OTHER DISCLOSURES: Except as described previously, we will not use or disclose information from your record unless you authorize (permit) in writing to do so. You may revoke your permission, which will be effective only after the date of your written revocation.

Disclosures Made With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

YOU HAVE RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION: You have the following rights regarding your health information, provided that you make a written request to invoke the right on the form provided by Marriage and Family Services, Inc.

Right to request restrictions. You may request limitations on your mental health information we may disclose, but we are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency mental health services.

Right to confidential communications. You may request communications in a certain way or at a certain location, but you must specify how or where you wish to be contacted.

Right to request clarification of the record. If you believe that the information we have about you is incorrect or incomplete you may ask to add clarifying information. You may ask for a form for that purpose and the form will require certain specific information. Marriage and Family Services, Inc. is not required to accept the information that you propose.

Right to inspect and copy. You may have the right to inspect and copy your mental health information regarding decisions about your care; however, psychotherapy notes may not be inspected and copied. 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. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that
a copy of your PHI be provided to another person. If your request is denied; you may request a review of the denial by another licensed mental health professional chosen by Marriage and Family Services, Inc. Marriage and Family Services, Inc. will comply with the outcome of the review.

Right to accounting of disclosures. You may request a list of the disclosures of your mental health information that have been made to persons or entities other than for mental health services or health care operations in the last eight (8) years, but not prior to June 1st, 2013.

Right to breach notification. If there is a breach of unsecured PHI concerning you, we may be
required to notify you of this breach, including what happened and what you can do to protect yourself.

Right to a copy of this notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy. You may print out a copy of this notice from our website.

Right to amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.

REQUIREMENTS REGARDING THIS NOTICE: Marriage and Family Services, Inc. is required to provide you with this Notice that governs our privacy practices. Marriage and Family Services, Inc. may change its policies or procedures in regard to privacy practices. If and when changes occur, the changes will be effective for mental health information we have about you as well as any information we receive in the future. Any time you come in to Marriage and Family Services, Inc. for an appointment, you may ask for and receive a copy of the Privacy Notice that is in effect at the time.

COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with Marriage and Family Services, Inc. or with the HHS Office of Civil Rights. You will not be penalized or retaliated against in any way for making a complaint. Contact: Marriage and Family Services, Inc. and ask to speak to the person/official responsible for privacy at 561-503-3059.

If you have a complaint; if you have any questions about this notice; if you wish to request restrictions on uses and disclosure for health care, mental health services, or operations; you may obtain any of the forms mentioned to exercise your individual rights described above.