Restoration Therapy of Columbus

6209 Riverside Drive, Suite 200A Dublin OH 43017-5098 / PH: 614 654-0120

Notice of Policies and Practices to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW MENTAL HEALTH AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes in most instances without your consent under HIPAA, but I will obtain consent in another form for disclosing PHI for other reasons, including disclosing PHI outside of my practice, except as otherwise outlined in this Policy. In all instances I will only disclose the minimum necessary information in order to accomplish the intended purpose. To help clarify these terms, here are some definitions:

• “PHI” refers to information in your health record that could identify you.

• “Treatment, Payment and Health Care Operations”

  • – Treatment is when I provide, coordinate or manage your health care and other services related to your

  • health care. An example of treatment would be when I consult with another health care provider, such as

  • your family physician or another therapist.

  • - Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose

  • your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or

  • coverage, which would include an audit.

  • - Health Care Operations are activities that relate to the performance and operation of my practice.

  • Examples of health care operations are quality assessment and improvement activities, business-related

  • matters such as audits and administrative services, and case management and care coordination.

• “Use” applies only to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances, when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information, including uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI. Examples of disclosures requiring an authorization include disclosures to your partner, your spouse, your children, except in some limited instances where they are involved in your health care, in which case I will obtain your consent first. Any disclosure involving psychotherapy notes, if I maintain them, will require your signed authorization, unless I am otherwise allowed or required by law to release them. You may revoke an authorization for future disclosures, but this will not be effective for past disclosures which you have authorized.

III. Uses and Disclosures Requiring Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization as allowed by law, including under the following circumstances:

• Serious Threat to Health or Safety: If I believe that you pose a clear and substantial risk of imminent serious

  harm, or a clear and present danger, to yourself or another person I may disclose your relevant confidential

  information to public authorities, the potential victim, other professionals, and/or your family in order to protect

  against such harm. If you communicate to me an explicit threat of inflicting imminent and serious physical

  harm or causing the death of one or more clearly identifiable victims, and I believe you have the intent and

  ability to carry out the threat, then I may take one or more of the following actions in a timely manner: 1) take

  steps to hospitalize you on an emergency basis, 2) establish and undertake a treatment plan calculated to

  eliminate the possibility that you will carry out the threat, and initiate arrangements for a second opinion risk

  assessment with another mental health professional, 3) communicate to a law enforcement agency and, if

  feasible, to the potential victim(s), or victim's parent or guardian if a minor, all of the following information: a)

  the nature of the threat, b) your identity, and c) the identity of the potential victim(s). I will inform you about

  these notices and obtain your written consent, if I deem it appropriate under the circumstances.

• Worker’s Compensation: If you file a worker’s compensation claim, I may be required to give your mental

  health information to relevant parties and officials.

• Felony Reporting: I am allowed to report any felony that you report to me that has been or is being

  committed.

• For Health Oversight Activities: I may use and disclose PHI if a government agency is requesting the

  information for health oversight activities. Some examples could be audits, investigations, or licensure and

  disciplinary activities conducted by agencies required by law to take specified actions to monitor health care

  providers, or reporting information to control disease, injury or disability.

• For Specific Governmental Functions: I may disclose PHI of military personnel and veterans in certain

  situations, to correctional facilities in certain situations, and for national security reasons, such as for protection

  of the President.

• For Lawsuits and Other Legal Proceedings: If you are involved in a court proceeding and a request is made

  for information concerning your evaluation, diagnosis or treatment, such information is protected by law. I

  cannot provide any information without your (or your personal or legal representative’s) written authorization,

  or a court order, or at times an administrative subpoena, unless the information was prepared for a third party.

  If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a

  court would be likely to order me to disclose information. If a patient files a complaint or lawsuit against me, I

  may disclose relevant information regarding that patient in order to defend myself.

• Abuse, Neglect, and Domestic Violence: If I know or have reason to suspect that a child under 18 years of age

  or a developmentally disabled, or physically impaired child under 21 years of age has suffered or faces a threat

  of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates

  abuse or neglect of the child or developmentally disabled individual under 21, the law requires that I file a

  report with the appropriate government agency, usually the County Children Services Agency. Once such a

  report is filed, I may be required to provide additional information. If I have reasonable cause to believe that a

  developmentally disabled adult, or an elderly adult in an independent living setting or in a nursing home, or an

  animal is being abused, neglected, or exploited, the law requires that I report such belief to the appropriate

  governmental agency. Once such a report is filed, I may be required to provide additional information. If I know

  or have reasonable cause to believe that a patient or client has been the victim of domestic violence, I must note

  that knowledge or belief and the basis for it in the patient’s or client’s records.

• To Coroners and Medical Examiners: I may disclose PHI to coroners and medical examiners to assist in the

  identification of a deceased person and to determine a cause of death.

• For Law Enforcement: I may release health information if asked to do so by a law enforcement official in

  response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal

  requirements.

• Required by Law. I will disclose health information about you when required to do so by federal, state or local

  law.

• Public Health Risks. I may disclose health information about you for public health reasons in order to prevent

  or control disease, injury or disability; or report births, deaths, non-accidental physical injuries, reactions to

  medications or problems with products.

• Information Not Personally Identifiable. I may use or disclose health information about you in a way that

  does not personally identify you or reveal who you are.

• SUD Treatment Information. If I receive or maintain any information about you from a substance use

  disorder treatment program that is covered by 42 CFR Part 2 (a “Part 2 Program”) through a general consent

  you provide to the Part 2 Program to use and disclose the Part 2 Program record for purposes of treatment,

  payment or health care operations, I may use and disclose your Part 2 Program record for treatment, payment

  and health care operations purposes as described in this Notice. If I receive or maintain your Part 2 Program

  record through specific consent you provide to me or another third party, I will use and disclose your Part 2

  Program record only as expressly permitted by you in your consent as provided to me.

• In no event will I use or disclose your Part 2 Program record, or testimony that describes the information

  contained in your Part 2 Program record, in any civil, criminal, administrative, or legislative proceedings by any

  Federal, State, or local authority, against you, unless authorized by your consent or the order of a court after it

  provides you notice of the court order.

  Other uses and disclosures will require your signed authorization, unless the use or disclosure is allowed or required

  by law.

IV. Patient’s Rights and Duties

Patient’s Rights:

• Right to Request Restrictions and Disclosures–You have the right to request restrictions on certain uses

  and disclosures of protected health information about you for treatment, payment or health care operations.

  However, I am not required to agree to a restriction you request, except under certain limited

  circumstances, and will notify you if that is the case. One right that I may not deny is your right to request

  that no information be sent to your health care plan if payment in full is made for the health care service. If

  you select this option then you must request it ahead of time and payment must be received in full each

  time a service is going to be provided. I will then not send any information to the health care plan for that

  session unless I am required by law to release this information.

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You

  have the right to request and receive confidential communications of PHI by alternative means and at

  alternative locations. If your request is reasonable, then I will honor it.

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental

  health and billing records used to make decisions about you for as long as the PHI is maintained in the

  record, except under some limited circumstances. If I maintain the information in an electronic format you

  may obtain it in that format. This does not apply to information created for use in a civil, criminal or

  administrative action or proceeding. I may charge you reasonable amounts for copies, mailing or associated

  supplies under most circumstances. I may deny your request to inspect and/or copy your record or parts of

  your record in certain limited circumstances. If you are denied copies of or access to your PHI, you may

  ask that my denial be reviewed. Under certain circumstances where I feel, for clearly stated treatment

  reasons, the disclosure of your record might have an adverse effect on you, I will provide your records to

  another mental health therapist of your choice if that is allowable under state and federal law.

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained

  in the record. I may deny your request, but will note that you made the request. Upon your request, I will

  discuss with you the details of the amendment process.

• Right to an Accounting – With certain exceptions, you generally have the right to receive an accounting of

  disclosures of PHI, not including disclosures for treatment, payment or health care operations, for records

  on file for the past six years. On your request I 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 me upon request,

  even if you have agreed to receive the notice electronically.

  My Duties:

  • I am required by law to maintain the privacy of PHI, to provide you with this notice of my legal duties and

    privacy practices with respect to PHI, and to abide by the terms of this notice.

  • I reserve the right to change the privacy policies and practices described in this notice and to make those

    changes effective for all of the PHI I maintain.

  • If I revise my policies and procedures, which I reserve the right to do, I will make available a copy of the

    revised notice to you on my website, if I maintain one, and one will always be available at my office. You

    can always request that a paper copy be sent to you by mail.

  • In the event that I learn that there has been an impermissible use or disclosure of your unsecured PHI,

    unless there is a low risk that your unsecured PHI has been compromised, I will notify you of this breach.

V. Complaints

If you are concerned that I have violated your privacy rights, or you disagree with a decision I make about access to

your records, you may file a complaint with me and I will consider how best to resolve your complaint. Contact me,

the Privacy Officer, if you wish to file a complaint with me. In the event that you aren’t satisfied with my response

to your complaint, or don’t want to first file a complaint with me, then you may send a written complaint to the

Secretary of the U.S. Department of Health and Human Services in Washington, D.C., 200 Independence Avenue

S.W., Washington, D.C. 20201, Ph: 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/compliants/.

There will be no retaliation against you for filing a complaint.

VI. Effective Date:

This notice is effective as of January 10, 2026.

VII. Privacy and Security Officer:

I act as my own Privacy and Security Officer. My contact information is listed at the beginning of this form.