Harmony Holistic Wellness LLC - Notice of Privacy Practices
The privacy of your health information is important to us. We will maintain the privacy of your health information, and we will not disclose information to others unless you tell me to do so, or unless the law authorizes or requires me to do so. A federal law commonly known as HIPAA (Health Insurance Portability and Accountability Act) requires that we take additional steps to keep you informed about how we may use information that is gathered in order to provide mental health services to you.
As part of this process, we are required to provide you with the attached Notice of Privacy Practices and to request that you sign below as written acknowledgement that you have received a copy of the Notice. The Notice describes how we may use and disclose your protected health information to carry out treatment, payment, or healthcare operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding health information I maintain about you and a brief description of how you may exercise these rights. Please let me know if you have any questions or concerns about this Notice.
NOTICE OF PRIVACY PRACTICES
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.
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 I may use and disclose your PHI in accordance with applicable law and the American Counseling Association Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
We are required to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at the time. we will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request or providing one to you at your next appointment.
How We May Use and Disclose Health Information About You:
• For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.
• For Payment: We may use and disclose PHI so that we can provide the necessary information for your insurance carrier, explaining the treatment services you received. This will only be done with your authorization. Examples of payment-related activities are making a determination of 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.
• For Health Care Operations: We may use or disclose, as needed, your PHI in order to support my business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have 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.
• For Communication with You: When we need to contact you by telephone, we will use the number you have given me on the contact information form to do this.
• As Required by Law: Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigation or determining my compliance with the requirements of the Privacy Rule.
• Without Authorization: The following is a list of the categories of uses and disclosures permitted by HIPAA without authorization. Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of situations. When following any legal obligations in my work, we strive to center the agency, informed choice, and freedom of the people we serve.
As a physician licensed in this state, it is my practice to adhere to more stringent privacy requirements for disclosures without authorization. The following language addresses these categories to the extent consistent with the ACA Code of Ethics and HIPAA.
• Child Abuse or Neglect: We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.
• Judicial and Administrative Proceedings: We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order, or similar process.
• Deceased Patients: We 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 that have been deceased for more than fifty (50) years is not protected under HIPAA.
• Medical Emergencies: We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. We 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: We 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.
• Workers' Compensation claims: We may disclose information to your workers’ compensation claims directly involved in your treatment based on your consent or as necessary to prevent serious harm.
• Health Oversight: If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.
• Law Enforcement: We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), 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 in connection with a crime on the premises.
• Specialized Government Functions: We 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 by law, we 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: We 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.
• Verbal Permission: We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
• With Authorization: Use and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. Your treatment will not be affected if you choose not to sign an authorization.
Your Rights Regarding your PHI:
You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your request in writing to me.
• 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 may be 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.
• Right to Amend: If you feel that the PHI we have about you is incorrect or incomplete, you may ask me to amend the information although we are not required to agree to the amendment.
• Right to an Accounting of Disclosures: You have the right to request an accounting of certain of the disclosures that I make of your PHI.
• 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. We are not required to agree to your request.
• Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
• Right to a Copy of this Notice: You have the right to a copy of this notice.
• Privacy and Security: We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
• Changes to the terms of this notice: We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.
• Complaints: If you believe that we have violated your privacy rights, you have the right to file a complaint in writing to the Privacy Officer at (615) 499-6443.
You can file with the U.S. Department of Health and Human Services – Office for Civil Rights by sending a letter to: 200 Independence Ave. SW, room 509F HHH building, Washington, D.C. 20201. Over the phone: 1(800) 368-1019 Online at: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
We will not retaliate against you for filing a complaint.
The effective date of this Notice is July 2nd, 2026.