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. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OF PRIVACY

PRACTICES, PLEASE CONTACT FOUNDATIONS THERAPY AND CONSULTING.

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information.

We make a record of the medical care we provide and may receive such records from others. We use these records to provide

or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed

by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly.

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal

duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach

of unsecured protected health information. This notice describes how we may use and disclose your medical information. It

also describes your rights and our legal obligations with respect to your medical information. If you have any questions about

this Notice, please contact us at the phone number listed above.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our

responsibilities to help you.

● Receive notice of our policies and procedures used to protect your protected information;

● Request that certain uses and disclosures of your protected information be restricted, provided, however, if

we release the information without your consent or authorization, we have the right to refuse your request;

● Access to your protected information be amended, although we are not required to grant your request;

● Obtain an accounting of certain disclosures by us of your protected information for the past six (6) years;

● Revoke any prior authorizations for use or disclosure of protected information, except to the extent that action has

already been taken; and

● Request that communications of your protected information are done by alternative means or at

alternative locations.

● You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care

operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-

of-pocket in full.

● Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and

other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you

agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost-

based fee for doing so.

● If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you

have the right to request that we correct the existing information or add the missing information. we may say “no” to

your request, but we will tell you why in writing within 60 days of receiving your request.

● The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you

have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you

also have the right to request a paper copy of it.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we

share your information, talk to us. Tell us what you want us to do, and we will follow your instructions.

● We will not use or disclose your PHI for marketing purposes.

● We will not sell your PHI in the regular course of our business.

Uses and Disclosures

Foundations Therapy and Consulting, LLC, collects health information about you and stores it in a chart (on a computer

system). This is your medical record. The medical record is the property of Foundations Therapy and Consulting, LLC, but the

information in the medical record belongs to you.

Generally, your protected information may be used and disclosed by us only with your expressed written authorization. This

written authorization includes to whom the information may be disclosed, what information may be disclosed, and for what

purpose. You may revoke this authorization at any time, although any information released prior to the revocation may be used

as stated on the consent.

There are some exceptions to this general rule. The law permits us to use or disclose your health information for the

following purposes:

Treatment Purposes: We may use or disclose your protected information for treatment purposes to doctors,

nurses, hospitals, for instance, in order to facilitate your treatment.

Communicating Appointment Reminders: we may use and disclose your PHI to contact you to remind you that you have an

appointment with us.

Payment Purposes: Your protected information may be used or disclosed to your insurance company, for instance, for

payment purposes as it may be necessary to disclose this information so that we may properly receive payment for

treatment and services provided.

Health Care Operations: Your protected information may be used or disclosed for health care operations. For example,

record review related to quality assurance and improvement activities.

Compliance and Quality Assurance: We may release your protected information to another individual or entity covered by

the HIPPA privacy regulations that has a relationship with you for fraud and abuse detection or compliance purposes,

quality assessment and improvement activities, or review, evaluation or training of professionals or students.

Oversight Activities: Your protected information may be used or disclosed to an oversight agency for activities authorized

by law. Examples of oversight activities include audits, investigations, and inspections. In most cases, the oversight

activity will be for the purpose of overseeing services and agency compliance with certain laws and regulations.

Judicial and Administrative Proceedings: If you are involved in a lawsuit or other administrative proceeding, we may release

your protected information in response to a court or administrative order. We may also release protected information

pursuant to a subpoena or discovery request, but only if efforts have been made by the requestor to provide you with

notice of the request and you have failed to object or the objection was resolved in favor of disclosure, or in the

alternative, the requestor has obtained a protective order protecting the requested information.

Law Enforcement: We may release your protected information to law enforcement officials when required or permitted by

federal or state law to do so.

Public Safety: We may, and are sometimes required by law, to disclose your health information to appropriate persons in order

to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

Emergency Circumstances: Protected information may be disclosed to personnel who have a need for information about a

client, such as for the purpose of treating a medical or mental condition which poses an immediate threat to the health

and safety of any individual or the public and which requires immediate intervention.

Individuals Involved in Your Care: We may give out your protected information to a friend or family member who is

helping with your care or with payment for your care. However, prior to sharing your protected information in this

instance we will first attempt to obtain your verbal or written consent. An example of when obtaining such consent

would not be feasible would be if you are involved in a serious accident and unavailable to give your consent and it

is necessary for us to speak with your emergency contact or other responsible party.

Mandatory Reporting of Child Abuse/Dependent Adult Abuse and Neglect: In the event that there is reason to

suspect that child abuse or dependent adult abuse or neglect has occurred, your protected information may be

disclosed as required by law.

As Authorized by Law: We will disclose your protected information for reasons not described above when required by law

to do so.

More Stringent Laws: Some of your protected information may be subject to other laws and regulations and are afforded

greater protection that what is outlined in this Notice. For instance, HIV/AIDS, substance abuse, and mental health

information is often given more protection. In the event your protected information is afforded greater protection under

federal or state law, we will comply with the applicable law.

Breach Notification: In the case of a breach of unsecured protected health information, we will notify you as required by

law. We will communicate with you about information related to the breach. We may also provide notification by other

methods as appropriate.

You have the right to object to certain uses and disclosures

We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment

for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in

emergency situations.

Our Responsibilities

In the course of treatment, information regarding your care may be created and/or received by us. Information which can be

used to identify you and which relates to your past, present or future physical or mental condition, receipt of care or

payment for care is considered protected information and is protected by federal and state law. Federal law imposes certain

obligations and duties upon providers of services with respect to your protected information. Specifically, we are required

to:

● Provide you with notice of our legal duties and policies regarding the use and disclosure of your protected

information;

● Maintain the confidentiality of your protected information in accordance with state and federal law; ∙ Honor

your requested restrictions regarding the use and disclosure of your protected information, unless under the

law we are authorized to release your protected information without your authorization.

● Allow you to inspect and copy your protected information;

● Act on your request to amend protected information, although we are not required to amend the protected

information, within sixty (60) days and notify you of any delay which would require us to extend the deadline

by the permitted thirty (30) day extension;

● Accommodate reasonable requests to communicate protected information by alternative means or methods;

and

● Abide by the terms of this notice.

We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we

are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised

Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was

created or received. We will keep a copy of the current notice posted in our office, and a copy will be available at your

request. We will also post the current notice on our website.

This notice has been provided to you as a summary of how we will use your protected information and what your rights with

respect to your protected information are. If you have any questions or would like more information regarding your

protected information, please contact your counselor. If you believe your privacy rights have been violated, you may file a

complaint with our office by contacting your counselor. He or she will provide you with specific information regarding the

agency’s grievance policy. You may also file a complaint with the Secretary of Health and Human Services. There will be no

retaliation for the filing of a complaint.

Secure Communication

Foundations Therapy and Consulting, LLC uses Secure Messaging through SimplePractice. Secure Messaging provides safe,

secure, and HIPAA compliant communication to SimplePractice, making it easy to securely communicate with your clinician. Staff

at Foundations Therapy and Consulting can assist you with accessing and using this method, and more information can be found

here: https://support.simplepractice.com/hc/en-us/articles/360043411252-Getting-started-guides-for-clients-How-to-use-

Secure-Messaging#howtousese

Email Notice

Electronic mail transmissions cannot be guaranteed confidential. Please refrain from use of email if concerned about the lack

of ensured confidentiality. Emails are not guaranteed secure and, by signing the below you release Foundations Therapy and

Consulting, LLC, from any breach in confidentiality when choosing to use email to communicate with your counselor.

Upheal Notice

Foundations Therapy and Consulting, LLC uses external providers to enhance services including the Upheal platform. Upheal

empowers counselors to concentrate on their services by offering automated notes and analytics for client conversations. As a

part of this process, Upheal handles protected health information for counselors, adhering to HIPAA regulations as a Business

Associate.

Your clinician has signed a Business Associate Agreement (BAA) to protect data that is shared with Upheal. Under the BAA,

Upheal adheres to regulations such as the HIPAA Security Rule and Privacy Rule. This ensures that electronic health information

(ePHI) is safeguarded through appropriate administrative, physical, and technical measures, ensuring its confidentiality, integrity,

and security. You can learn more about Upheal and its privacy practices at www.upheal.io/privacy.