PURPOSE OF PRIVACY NOTICE

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI). It is in accordance with applicable law, including the Health Insurance Portability and Accountability (HIPAA) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” or “PHI” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of this Notice at any time. A new Notice will be effective for all PHI that we maintain at that time. Please review it carefully.

I. USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION FOR THE PURPOSES OF PROVIDING SERVICES.

State and federal laws allow us to use and disclose your PHI, without your prior authorization, by your therapist, our office staff, and others outside our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the therapist’s practice, and any other use required by law.

• Treatment: Arevalo Counseling & Mentoring, LLC (AC&M, LLC) will use and disclose your PHI to provide, coordinate or manages your health care with doctors, medical staff, another health care provider and/or mental health clinician(s). We may also share your health information with treatment providers for your future care for other treatment reasons. In addition, we may use or share your health information in response to an emergency.

• Payment: AC&M, LLC will use and disclose your PHI, as needed, to submit claims/bill and obtain payment for the treatment and services you receive. For these billing and payment purposes, we may disclose your health information to your payment source, including insurance or managed care company, Medicaid, or another third-party payer.

• Health Care Operations: AC&M, LLC may use or disclose your PHI in order to support for business operations, such as quality assurance and improvement actions, reviewing the competence and qualifications of health care professionals, medical review, legal services, audit roles, and general administrative purposes. The law may need us to share your health information with representatives of federal and State regulatory agencies that oversee our business if we have an active contract with such agencies. 

• Minors: PHI of minors will be disclosed to their parents or legal guardians, unless prohibited by law.

• Other Disclosures such as Business Associates: We may share your PHI with our business associates so they can perform the job we have asked them to do. Some services provided by our business associates include a billing service, payment portals, record storage company, communication software (such as e-mail or text messaging for scheduling) or legal or accounting consultants. To protect your health information, we have written contracts with our business associates requiring them to safeguard your information.

II. OTHER USES & DISCLOSURES NOT REQUIRING YOUR CONSENT NOR AUTHORIZATION

In accordance with applicable laws and ethical standards permitted by HIPAA, the following is a list of the categories of uses and disclosures about you not requiring your authorization.

• Serious Threat to Your Own Health and/or Safety: If you have made a threat, or in our clinical judgement we believe disclosure is necessary to protect you from a clear and substantial risk of imminent, serious harm, we may disclose confidential information from your records to emergency contacts, emergency personnel, and/or other providers.

• Serious Threat to Others’ Health and/or Safety: If you have made a threat, or when we believe others are at imminent risk of harm or danger, the law requires AC&M, LLC to warn and protect all parties. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the patient.

• Child Abuse:  If AC&M, LLC  has reasonable cause to believe that a child (age 0-18) has been abused or neglected,  AC&M, LLC must report this and relevant information, within 24 hours, to the Division of Child and Family Services, the county agency which provides child welfare services or a law enforcement agency.

• Adult/Vulnerable Person Abuse: If AC&M, LLC has reasonable cause to believe that an adult person (age 60 or older) or a vulnerable person (age 18 and older) has been abused, neglected, exploited or isolated, AC&M, LLC must make a report to the local office of the Nevada Department of Human Resources Division of Aging Services, the police department or sheriff's office, or other appropriate agency within 24 hours after becoming aware of this information.

• 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. 

• Health Oversight: If AC&M, LLC receives a request from the Marriage and Family Therapists Boards in States therapists are licensed in (California, Nevada, Arizona, and Florida) with respect to an inquiry or complaint about professional conduct, AC&M, LLC must make available any record relevant to such inquiry.

• Judicial or Administrative Proceedings: Communication between a client and certain mental health care providers is “privileged” by law. This means that the provider may not disclose any information acquired from the client that was necessary to provide professional services. However, if you are involved in a lawsuit or a dispute, we may disclose your health information in response to a legitimate court or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other legal procedure by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the health information requested. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case. If AC&M, LLC becomes involved in your legal proceedings, you and your legal team will be charged for our professional expertise and time, which is billed at a higher rate than  our psychotherapy sessions. Payment is required prior to appearance in court and prior to us releasing/compiling documentation. Additionally, in instances of a lawsuit instigated by you against us as service providers, your confidentiality will be waived. 

• Court Ordered Treatment: If you are in therapy by order of a court of law, the progress of the treatment  must be  revealed to the probation officer and/or court personnel.

• Inmates: If you are an inmate or under the custody of a law enforcement official, parole office or probation officer, we may release your health information to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with health care and for the safety and security of the correctional institution. 

• Patriot Act of 2001 Section 215:  Allows the government to obtain a secret court order requiring third parties, such as telephone companies, to hand over any records or other “tangible thing” if deemed “relevant” to an international terrorism, counterespionage, or foreign intelligence investigation.

• Military Personnel: If you are a member of the armed forces, we may disclose your health information as mandated by military authorities or the Department of Veterans Affairs. 

• Worker’s Compensation: If you file a worker’s compensation claim, then AC&M, LLC must submit to your employer’s insurer or a third-party administrator, a report on services rendered.

• Special Rules for Disclosure of Psychiatric, Substance Abuse, & HIV-Related Information: For disclosures of health information about psychiatric conditions, substance abuse, or HIV-related testing and treatment, special rules may apply. In general, health information relating to care or psychiatric conditions, substance abuse or HIV-related testing and  treatment may not be disclosed, unless the disclosure is to provide appropriate medical intervention or as required or authorized by federal or state law.

• Communicable Diseases: We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. 

• Collections: In cases during which a collection agency is required to pursue collections for services provided but not paid per AC&M, LLC policies and/or if you are disputing charges to your credit/debit card per policy.

• Coroners, Medical Examiners, and Funeral Directors: AC&M, LLC may release PHI to a coroner or medical examiner for the purposes of identifying a deceased person or determining the cause of death. AC&M, LLC may also release PHI to funeral directors as necessary to carry out their duties.

III. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION PERMITTED WITHOUT AUTHORIZATION, BUT WITH AN OPPORTUNITY FOR THE INDIVIDUAL TO OBJECT

We may use your protected health information to maintain a directory of clients in our program. The information included in the directory will be limited to your name, your phone number, and your condition described in general terms. In addition, if applicable, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. You may object to these disclosures. If you do not object to these disclosures, or we determine in the exercise of our professional judgment that it is in your best interest for us to disclose information that is directly relevant to the person’s involvement with your care, we may disclose your protected health information.

IV. USES & DISCLOSURES REQUIRING YOUR AUTHORIZATION

Unless otherwise permitted or required by law as described in this notice above, we will not use or disclose your protected health information without your written authorization. An “authorization” is for specific uses and are written permission above and beyond the general consent. In those instances, when we are asked for information for purposes not described in this notice (i.e. outside of treatment, payment and health care operations) we will obtain an authorization from you before releasing this information. You may revoke an authorization, at any time, in writing. However, we cannot take back any uses or disclosures (1) already made with your permission or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy. AC&M, LLC does not sell protected health information to a third party.

IV. PATIENT’S RIGHTS

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request that we do not disclose your protected health information to friends or family members who may be involved in your care, or for notification purposes as described earlier in this notice. Your request must be made in writing and must state the specific restriction requested and the individuals to whom the restriction applies. However, AC&M, LLC is not required to agree to a restriction you request, and if so we will notify you.

• Right to Receive Confidential Communications by Alternative Means and Locations – For example, you may not want a family member to know that you are seeing a clinician. Upon your request, AC&M, LLC will send documents to another address. Requests for confidential communications must be made in writing.

• Right to Inspect and Copy – You have the right to inspect or obtain a copy of PHI in mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. AC&M, LLC may deny your access to PHI if, in our professional judgment, we determine that the access requested is likely to endanger you or another person or is likely to cause substantial harm to another person referenced within the protected health information. You have a right to request a review of a denial of access. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing, or other costs incurred by us as a result of complying with your request. Requests for access to your protected health information must be made in writing.

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. AC&M, LLC may deny your request. On your request, AC&M, LLC personnel will discuss with you the details of the amendment process. Requests for access to your protected health information must be made in writing and must include reason(s) to support the requested amendment(s).

• Right to an Accounting of Disclosures of PHI – You have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization. On your request, AC&M, LLC personnel will discuss with you the details of the accounting process.

• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from AC&M, LLC upon request, even if you have agreed to receive the notice electronically.

• Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket – You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for our services.

• Right to Be Notified if There is a Breach of Your Unsecured PHI – You have a right to be notified if there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI that PHI has not been encrypted to government standards. Examples of a breach include: (1) Stolen or improperly accessed PHI; (2) PHI inadvertently sent to the wrong provider; and (3) Unauthorized viewing of PHI. A use or disclosure of PHI that violates the Privacy Rule is presumed to be a breach unless we demonstrate that there is a “low probability that PHI has been compromised.” Please note: In regards to communicating with our office, the safest (i.e., most protected) form of communication is via phone. Although our office maintains an encrypted email server for all members of our staff, most servers (e.g., Gmail, Yahoo, Outlook, etc.) used by clients are not encrypted, and therefore are more vulnerable to a breach of PHI. However, we are still happy to correspond with you via email if that is your preferred method of communication.

V. AREVALO COUNSELING & MENTORING, LLC PROFESSIONAL DUTIES

• AC&M, LLC is required by law to maintain the privacy of PHI and to provide you with this Notice of Privacy Practices of our legal duties and privacy practices with respect to PHI.

• AC&M, LLC reserve the right to change the privacy policies and practices described in this notice. Unless AC&M, LLC notifies you of such changes, however, AC&M, LLC is required to abide by the terms currently in effect.

• If AC&M, LLC revises policies and procedures, AC&M, LLC will notify you in writing or by giving you the revision in person.

VI. COMPLAINTS

If at any time, for any reason, you are dissatisfied with our services, please let us know. You may inform at anytime by calling (702) 970-3535 or emailing contactus@acm-llc.com. We will do our best to resolve your concern and if needed, we will provide you with a referral. If we can not resolve your concern, you may report your complaint to:

• Nevada Board of Examiners for Marriage Family Therapists and Clinical Professional Counselors at (702) 486-7388.

• Arizona Board of Behavioral Health Examiners at (602) 542-1882.

• California Board of Behavioral Sciences by visiting https://www.bbs.ca.gov/consumers/consumer_complaints.html

• Florida Board of Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling at https://www.floridahealth.gov/licensing-and-regulation/enforcement/index.html

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services (HHS) via web (https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf), call (202) 619-0257 or toll free (877) 696-6775, or mail to:

AC&M, LLC will not retaliate against you for filing a complaint.

We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. If we change this notice, we will provide you with a new copy.

This notice is effective as of January 2017. 

Revised July 2023.

Secretary of the US

Department of Health and Human Services

200 Independence Ave S.W.

Washington, D.C. 20201