THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS INFORMATION IS BEING PROVIDED TO YOU AS REQUIRED BY LAW.
Uses and Disclosures for Treatment, Payment, and Health Care Operations
Healing Wings and its staff may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. 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 Healing Wings Counseling & Consulatation, LLC or its staff provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when the Counseling Center and its staff consult with another health care provider, such as your family physician or another psychologist.
• Payment is when Healing Wings Counseling & Consultation, LLC and its staff obtain reimbursement for your healthcare. Examples of payment are when the Counseling Center and its staff disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
• Health Care Operations are activities that relate to the performance and operation of Healing Wings and its staff. 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 Healing Wings, LLC. and its staff such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of the Counseling Center and its staff, such as releasing, transferring, or providing access to information about you to other parties.
Uses and Disclosures Requiring Authorization
Healing Wings and its staff 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 Healing Wings is asked for information for purposes outside of treatment, payment and health care operations, Healing Wings will obtain authorization from you before releasing this information. Healing Wings will also need to obtain authorization before releasing your psychotherapy notes.
“Psychotherapy notes” are notes a Healing Wings psychologist, counselor, or social worker has made about our conversation during a private, group, joint, or family counseling session, which Healing Wings have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI and will not be released unless there are specific circumstances or a client has authorized with a HIPAA information release form.
You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that
Healing Wings has relied on that authorization; or
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.
Uses and Disclosures with Neither Consent nor Authorization
Healing Wings may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: If, in my professional capacity, a Healing Wings counselor know or suspect that a child under 18 years of age or a mentally retarded, 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, I am required by law to immediately report that knowledge or suspicion to the Children Services Agency, or a municipal or county peace officer.
Adult and Domestic Abuse: If a Healing Wings employee or counselor have reasonable cause to believe that an adult is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect, or exploitation, I am required by law to immediately report such belief to the County Department of Job and Family Services.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your evaluation, diagnosis, and treatment and the records thereof, such information is privileged under state and federal law and Healing Wings will not release this information without written authorization from you or your persona or legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered, also if there is a criminal investigation. You will be informed in advance if this is the case.
Serious Threat to Health or Safety: If a Healing Wings' counselor believes that you pose a clear and substantial risk of imminent serious harm to yourself or another person, Healing Wings 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 Healing Wings an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly identifiable victims, and a Healing Wings' counselor believes you have the intent and ability to carry out the threat, then Healing Wings is required by law to 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).
HIPAA helps mental health professionals to prevent harm--
Psychiatrists, psychologists, psychiatric nurses, clinical social workers, mental health counselors, and other professionals who provide treatment to patients with a mental health condition may share protected health information, including mental health information, in order to treat patients and prevent them from harming themselves or others.
when patients have thoughts of harming themselves or others, or when patients exhibit behavior that demonstrates a threat of harm to health or safety, mental health professionals need to be able to use their expertise and professional judgment to identify a potential or likely risk and determine who can help lessen the potential for harm. Several approaches are available under HIPAA to address situations where contacting a patient’s family, friends, or others involved in their care (including a personal representative) may be helpful in reducing the potential for harm:
A health or mental health professional may always share mental health information with a patient’s personal representative (if they have one).
A health or mental health professional may share mental health information with family, friends, or caregivers, if the patient agrees, or does not object, and the information is relevant to the family member, friend, or caregiver’s involvement with the patient’s health care or the payment for such care. For example, a psychotherapist may contact a close friend of a patient in crisis (who has brought the patient to sessions in the past) and enlist the friend’s assistance to take the patient to a psychiatric consult or to pick up new medication. Also, a therapist may contact a patient’s mother, if the patient’s mother has been involved in coordinating the patient’s appointments, to ensure the patient attends. If the patient is mentally incapacitated, the psychotherapist may decide that different rules may apply if the health or mental health provider receives federal funds in connection with a substance use disorder treatment program. This fact sheet does not address such rules.
Mental Health providers may have to make decisions about when to share mental health information based on their professional judgment about what is in the best interests of the patient or what is needed to prevent or lessen a risk of harm.
HIPAA helps mental health professionals by allowing
disclosing relevant mental health information to involved family, friends or caregivers is in the patients’ best interests, even if the patient is unable to agree or object.
• A health or mental health professional may contact anyone who is reasonably able to lessen the risk of harm when they believe that a patient presents a serious and imminent threat to the health or safety of a person (including the patient) or the public. HIPAA helps professionals by ensuring that mental health information can be shared to prevent harm when the provider believes that it is necessary and the information is shared with someone who can help lessen the potential harm. For example, if a patient tells their psychotherapist that they have persistent images of harming their spouse, the psychotherapist may:
notify the spouse;
call the patient’s psychiatrist or primary care doctor to review medications and develop a
plan for voluntary or involuntary hospitalization or other treatment;
call 911, if emergency intervention is required; and /or
notify law enforcement, if needed.
OCR would not second guess a health professional’s judgment about when a patient seriously and imminently threatens their own, or others, health or safety. For more information, see OCR’s Guidance on Sharing Mental Health Information: topics/mental-health/index.html.
Worker’s Compensation or Insurance: If you file a worker’s compensation claim or also has billed your insurance benefits on your behalf and Healing Wings may be required to give your mental health information to relevant parties and officials or for audits.
Patient’s Rights and Counselors’ Duties
Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, Healing Wings is not required to agree to a restriction you request.
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. (For example, you may not want a family member to know that you are seeing me. Upon your request, the Counseling agency will send your bills to another address but we will not email PMI as according to HIPAA law.
Right to Inspect and Copy – You have the right to inspect or obtain a copy of PHI and in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Healing Wings may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, Healing Wings will discuss with you the details of the request process and we charge a reasonable fee as Ohio Revised Code authorizes. (Subject to change fees as laws change accordingly).
Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Healing Wings may deny your request. On your request, Healing Wings will discuss with you the details of the amendment process.
Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, the Counseling Agency will discuss with you the details of the accounting process of your billing or you may receive an itemized statement by requesting it in writing or by asking at the time of your session.
Right to a Paper Copy – You have the right to obtain a paper copy of the notice from Healing Wings upon request, even if you have agreed previously to authorize HIPAA information - we will need a release of information for any copies thereof. Fees are ORC and are compliant with Ohio and HIPAA standards. If court or attorney, retainers will be necessary as we will involve our attorney as such for any contact with your attorney. Please see our Attorney fee policy. We are not a practice that will go or testify in court. Our retainers will start at $2500 + to cover our fees, canceling appointments, etc. We reserve the right to change all fees in accordance with insurance contracts, the Ohio Revised Code, and HIPAA Federal laws.
Right to a List of Those with Whom We’ve Shared Your information– You generally have the right to receive an accounting of disclosures of PHI for six years prior to your request for which you have neither provided consent nor authorization, whom we shared it with and why (as described in Section III of this Notice). On your request, agency staff will discuss with you the details of the accounting process. We will provide one accounting per year for free but will charge a reasonable fee if you request another one within 12 months.
Right to 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 the authority and can act for you before we take any action.
Healing Wings Counseling and Consultation, LLC is required by law to maintain the privacy of PHI and to provide you with a notice of its legal duties and privacy practices with respect to PHI.
Healing Wings reserve the right to change the privacy policies and practices described in this notice according to the HIPAA Federal Laws and/or Ohio Revised Code and ethics. Unless Healing Wings will notify you of such changes, however, Healing Wings is required to abide by the terms currently in effect.
If Healing Wings revises my policies and procedures, Healing Wings will notify you in writing by mail or at your appointment to see if you would like a copy of our new policies if you are an active patient. An active patient is someone that is currently being seen or has been seen for services within three months preceding the revision of policies and procedures.
A right to request an alternative method of contact or communication: You have the right to ask to be contacted at a different location or in a different way. For example, you may want to have all written information mailed to your work address instead of to your home address or to one relative rather than another. We will agree to any reasonable request for other ways of contacting you. If you would like to ask for another way of being contacted, please submit your request in writing to our Medical Records Manager. Email – We can contact you or your representative by email if you request or if you have signed our Email or Text form that states the precautions of email and text communications. Please be aware that email may compromise the security and privacy of your protected health information.
Healing Wings Counseling & Consultation, LLC, Inc Privacy Notice Acknowledgment:
For certain health information, you can tell us your choices about what we share, in the following 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.
Share information in a disaster relief situation.
The following use and disclosures of PHI will only be made if we receive written authorization from you:
Most disclosures of psychotherapy notes
Uses and disclosures of PHI for marketing purposes
Sale of PHI under HIPAA
Other uses and disclosures not described in this notice.
We may contact you for fundraising efforts, but you can tell us not to contact you again.
Mental Health Provider’s Responsibilities:
Agency staff is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
Agency staff reserve the right to change the privacy policies and practices described in this notice. Unless agency staff notifies you of such changes, however, agency staff are required to abide by the terms currently in effect.
If agency staff revise these policies and procedures, the new policies and procedures will be posted on the agency web site:
The agency 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, notifying us in writing.
In the event of a breach, the agency will notify clients by written notice within 60 days of the date that the breach is discovered. Notices will be mailed to the last known address of the client so please keep us updated on your location.
Questions and Complaints
If you are concerned that Healing Wings has violated your privacy rights, or you disagree with a decision Healing Wings made about access to your records, you may contact Jerry Fetters, AGENT-and client's rights officer, Healing Wings Counseling & Consultation, LLC. 776 Peachblow Road, Lewis Center, OH 43035
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request or www.hipaa.gov.
This notice will go into effect on Jan. 4, 2013 and revised on 7-1-2019.
Healing Wings Counseling & Consultation, LLC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that it maintains. Healing Wings will provide you with a revised notice by mail if you are an active patient and inactive patients will have to resign forms if they become active or ask for forms to be sent.
Thank you for allowing us to serve you.
The Staff of Healing Wings Counseling & Consultation, LLC
Email/Text Form Authorization Form: If you would like to use these forms of communication, users must first review the vulnerabilities and authorize us to use your email and/or text. Please note that some forms do have extra charges for communication and will be discussed by your counselor.