This notice describes how medical information about you may be used and disclosed and how you can get access to this information. By signing the Universal Consent below, you agree that you have reviewed it carefully.  

“Protected Health Information“ (PHI) is information about you, including demographic  information, that may identify you or be used to identify you, and that relates to your past, present or future physical or mental health or condition, the provision of health  care services, or the past, present or future payment for the provision of health care.  

Your Rights Regarding Your PHI  

You have the right to:  

• Get a copy of your paper or electronic medical record  

• Correct your paper or electronic medical record  

• Request confidential communication 

• Ask us to limit the information we share  

• Get a list of those with whom we’ve shared your information 

• Get a copy of this privacy notice 

• Choose someone to act for you  

• File a complaint if you believe your privacy rights have been violated 

Our Uses and Disclosures  

We may use and share your information as we:  

• Treat you  

• Run our organization  

• Bill for your services  

• Help with public health and safety issues  

• Consult and collaborate with MLCWC Supervisors and Therapists regarding your care • Do research 

• Collaborate with Blueprint-Health.com for assessment and outcomes purposes • Comply with laws that may be in place now or in the future  

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.  

Get an electronic or paper copy of your records 

• You can ask to see or get an electronic or paper copy of your medical record and  other health information we have about you. Ask us how to do this. 

• We will provide a copy or a summary of your health information, usually within 30 days  of your request. We may charge a reasonable, cost-based fee.

 Ask us to correct your medical record  

• You can ask us to correct health information about you that you think is incorrect or  incomplete. Ask us how to do this.  

• We may say “no” to your request, but we’ll tell you why in writing within 60 days. 

• Request confidential communications  

• You can ask us to contact you in a specific way (for example, home or office phone) or  to send mail to a different address.  

• We will say “yes” to all reasonable requests.  

Ask us to limit what we use or share  

• You can ask us not to use or share certain health information for treatment, payment,  or our operations. We are not required to agree to your request, and we may say “no”  if it would affect your care.  

• 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 say “yes” unless a law requires us to share that information. 

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information  for six years prior to the date you ask, who we shared it with, and why. 

• We will include all disclosures except for those about treatment, payment, and health  care operations, and certain other disclosures (such as any you asked us to make).  We’ll provide one accounting a year for free but will charge a reasonable, cost-based  fee if you ask for another one within 12 months. 

Get a copy of this privacy notice  

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically, it will be accessed through your client portal.  

Choose someone to act for you  

• If you have given someone medical power of attorney or 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.  

File a complaint if you feel your rights are violated.  

• You can complain if you feel we have violated your rights by contacting us at  intake@mlcwellness.com 

• You can file a complaint with the 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/.  

• We will not retaliate against you for filing a complaint. 

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 in the situations described  below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:  

• Share information with your family, close friends, or others involved in your care. If you  are not able to tell us your preference, for example if you are unconscious, we may go  ahead and share your information if we believe it is in your best interest. We may also  share your information when needed to lessen a serious and imminent threat to health  or safety.  

• In these cases we never share your information unless you give us written permission:  Sharing of psychotherapy notes 

Our Uses and Disclosures  

If you give us permission, how would we typically use or share your health information?  We typically use or share your health information in the following ways.  

Treat you 

• We can use your health information and share it with other professionals who are  treating you or for the purposes of diagnostic assessment. Example: Your physician  and I may need to coordinate your care. We have a business associate agreement  with Blueprint-Health.com to provide assessment and outcomes measures that allow  us to individualize your care.  

Run our organization  

• We can use and share your health information to run our practice, improve your care,  collaborate with supervisors for case consultation and contact you when necessary.  Example: We use health information about you to manage your treatment and  services.  

Bill for your services  

• We can use and share your health information to bill and get payment from health  plans or other entities. Example: We give information about you to your health  insurance plan so it will pay for your services.  

How else can we use or share your health information? 

We are allowed or required to share your information in other ways – usually in ways  that contribute to the public good, such as public health and research. We have to meet  many conditions in the law before we can share your information for these purposes.  For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/ index.html. 

Help with public health and safety issues  

We can share health information about you for certain situations such as: 

• Reporting suspected abuse, neglect, or domestic violence  

• Preventing or reducing a serious threat to anyone’s health or safety 

Do research

• We can use or share your information for health research.  

Comply with the law  

• We will share information about you if state or federal laws require it, including with  the Department of Health and Human Services if it wants to see that we’re complying  with federal privacy law.

We can use or share health information about you:  

• For workers’ compensation claims  

• For law enforcement purposes or with a law enforcement official  • With health oversight agencies for activities authorized by law  

• For special government functions such as military, national security, and presidential  protective services  

Respond to lawsuits and legal actions  

• We can share health information about you in response to a court or administrative order 

Our Responsibilities  

• 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.