Firm Foundation Counseling LLC
401 West Bristol Street
Elkhart, IN 46514
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on February 12,2021
NOTICE OF PRIVACY PRACTICES
Notice of Privacy Practices
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.
Our Commitment to your privacy
Firm Foundation Counseling LLC is dedicated to maintaining the privacy of your personal health information as part of providing professional care. We are also required by law to keep your information private. These laws are complicated, but we must give you this important information.
Introduction
The Federal Health Insurance Portability and Accountability Act (HIPAA) requires mental health professionals to issue this official Notice of Privacy Practices. This notice describes how information about you is protected, the circumstances under which it may be used or disclosed and how you may gain access to this information. Please review it carefully.
For psychotherapy to be beneficial, it is important that you feel free to speak about personal matters, secure in the knowledge that the information you share will remain confidential. You have the right to the confidentiality of your medical and psychological information, and this practice is required by law to maintain the privacy of that information.
This practice is required to abide by the terms of the Notice of Privacy Practices currently in effect, and to provide notice of its legal duties and privacy practices with respect to protected health and psychological information.
Who Will Follow This Notice
Any health care professional authorized to enter information into your medical record, all employees, staff, and other personnel at this practice who may need access to your information must abide by this Notice. All subsidiaries, business associates (e.g., a billing service), sites and locations of this practice may share medical information with each other for treatment, payment purposes or health care operations described in this Notice. Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be shared.
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 accordance with Indiana law (IC 16-39-2), mental health records may only be disclosed with your written consent, unless otherwise required by law. When we use or disclose your health information, we make reasonable efforts to limit the information to the minimum necessary to accomplish the intended purpose. The following should help clarify these terms:
PHI refers to information in your health record that could identify you. For example, it may include your name, the fact you are receiving treatment here, and other basic information pertaining to your treatment.
Use applies only to activities within my office and practice group, such as sharing, employing, applying, utilizing, and analyzing information that identifies you.
Disclosure applies to activities outside of my office or practice group, such as releasing, transferring, or providing access to information about you to other parties.
Authorization is your written permission to disclose confidential health information. All authorizations to disclose must be made on a specific and required form.
Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. For example, with your written authorization Imay provide your information to your physician to ensure the physician has the necessary information to diagnose or treat you.
Payment Your PHI may be used, as needed, in activities related to obtaining payment for your health care services. This may include the use of a billing service or providing you documentation of your care so that you may obtain reimbursement from your insurer.
Health Care Operations are activities that relate to the performance and operation of my practice. I may use or disclose, as needed, your protected health information in support of business activities.
Written Authorizations to Release PHI
Any other uses and disclosures of your PHI beyond those listed above will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke your authorization at any time, in writing.
Uses and Disclosures without Authorization
Under certain circumstances, we may disclose your Protected Health Information (PHI) without your written consent or authorization, as required or permitted by federal and Indiana state laws. These exceptions include:
1. Child Abuse or Neglect
If we have reasonable cause to believe a child may be a victim of abuse or neglect, we are legally required to report this to the appropriate authorities.
2. Abuse of Vulnerable Adults
We must report suspected abuse, neglect, or exploitation of an elderly person or an adult with disabilities to appropriate state agencies, in compliance with Indiana law.
3. Health Oversight Activities
We may disclose PHI to government agencies responsible for oversight of the health care system, such as licensing, auditing, and investigation of complaints or disciplinary actions.
4. Legal Proceedings
If you are involved in a court proceeding and we receive a court order requiring the release of your records, we must comply. Without a court order, your PHI is considered privileged and will not be released without your written consent. This includes:
Information related to psychological treatment or evaluation.
Exceptions apply if the court orders a mental health evaluation or your treatment is being conducted for a third-party evaluation.
5. Law Enforcement
We may disclose limited information to law enforcement when required by law, such as:
Reporting a crime on the premises.
Responding to a valid subpoena or warrant (with appropriate safeguards).
Locating a missing person or reporting a serious threat to public safety.
6. Serious Threat to Health or Safety
If you communicate a specific and immediate threat of serious harm to yourself or another person, we may disclose information to individuals or authorities who can help prevent the threat.
7. Worker’s Compensation
We may disclose information necessary to comply with laws relating to workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses.
If there is a breach of unsecured protected health information that poses a significant risk of financial, reputational, or other harm to you, we are required to notify you without unreasonable delay and no later than 60 days after discovery of the breach.
Special Authorizations
Certain categories of information have extra protections by law, and thus require special written authorizations for disclosures.
Psychotherapy Notes – I will obtain a special authorization before releasing your Psychotherapy Notes. "Psychotherapy Notes" are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your record. These notes are given a greater degree of protection than PHI. Psychotherapy notes do not include session start/end times, modalities, diagnosis, treatment plan, medications, or clinical test results.
HIV Information – Special legal protections apply to HIV/AIDS related information. I will obtain a special written authorization from you before releasing information related to HIV/AIDS.
Alcohol and Drug Use Information – Special legal protections apply to information related to alcohol and drug use and treatment. I will obtain a special written authorization from you before releasing information related to alcohol and/or drug use/treatment. You may revoke all such authorizations (of PHI, Psychotherapy Notes, HIV information, and/or Alcohol and Drug Use Information) at any time, provided each revocation is in writing, signed by you, and signed by a witness. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
Patient’s Rights and Psychologist’s Duties
Patient’s Rights:
Right to Request Restrictions – You have the right to request restrictions on certain uses/disclosures of PHI. However, I am not required to agree to the request.
Right to Receive Confidential Communications by Alternative Means – You have the right to request and receive confidential communications by alternative means and locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.)
Right to Inspect and Copy – The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 5 business days of receiving your written request. If a letter/summary is requested, there will be a fee for this service.
Right to Amend – You have the right to request an amendment of PHI for as long as it is maintained in the record. I may deny your request. If so, I will discuss with you the details of the amendment process.
Right to an Accounting – You generally have the right to receive an accounting of all disclosures of PHI. I can 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 of Privacy Practices from me upon request.
Therapist’s Duties:
I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
If I revise my policies and procedures, I will notify you at our next session, or by mail at the address you provided me.
We are required to maintain your chart for a minimum period of time. In the state of Indiana, we are required to keep all documentation for a minimum of seven years.
How we use and disclose your protected health information with your consent
We will use the information we collect about you mainly to provide you with treatment, to arrange payment for our services, and for some other business activities that are called, in the law, health care operations. After you have read this notice we ask you to sign an acknowledgement form to let us use and share your information in these ways. If you do not consent and sign this for, we cannot treat you. If we want to use or send, share, or release your information for other purposes, we will discuss this with you and ask you to sign an authorization form to allow this.
Disclosing your health information without your consent
There are times when the laws require us to use or share your information. For example: 1. When there is a serious threat to your or another’s health and safety or to the public. We will only share information with persons who are able to help prevent or reduce the threat.
2. When we are required to do so by lawsuits and other legal or court proceedings.
3. If a law enforcement official requires us to do so.
4. For workers’ compensation and similar benefit programs.
Your rights regarding your health information:
1. You can ask us to communicate with you in a particular way or at a certain place that is more private for you. For an example, you can ask us to call you at home and not at work, to schedule or cancel an appointment. We will try our best to do as you ask.
2. You may ask us to limit what we tell people involved in your care or the payment for your care, such as family members and friends.
3. You have the right to look at the health information we have about you, such as your medical and billing records. You can get a copy of these records.
4. If you believe that the information in your records is incorrect or missing something important, you can ask us to make additions to your records to correct the situation. You have to make this request in writing and send it to our privacy office. You must also tell us the reasons you want to make the changes.
5. You have the right to a copy of this notice.
6. You have a right to file a complaint with our supervisor and with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care we provide to you in any way. You may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights at:
Website: https://www.hhs.gov/ocr/privacy/hipaa/complaints/
Phone: 1-800-368-1019
Email: OCRComplaint@hhs.gov
Phone Calls/Texting Policy
Terms and Conditions
By opting in to receive SMS messages from Firm Foundation Counseling LLC (“we,” “us,” “our”), you agree to these Terms and Conditions (Terms).
SMS Messaging Service
By providing my phone number, I consent to receive SMS text messages from Firm Foundation Counseling LLC for appointment reminders, feedback, and general two-way communication about my relationship with Firm Foundation Counseling LLC. Message and Data Rates may apply.
Message Frequency
You will receive more than one message from us unless you opt out. While messaging frequency varies, you will likely receive messages pertaining to your account with us as you request or up to four messages per month. We reserve the right to alter the frequency of messages at any time to increase or decrease the total number of messages. The company and carriers are not liable for delays or undelivered messages.
Message and Data Rates
Message and data rates may apply based on your mobile carrier’s terms.
Privacy Policy
Your information will be handled in accordance with our Privacy Policy which we provide in paper form.
Cancellation/Opt-Out Instructions
You can opt out of receiving SMS messages at any time by replying STOP to any message we send you. After you opt out of text messaging, you will receive one additional message confirming your request has been processed. You may also login to your client portal and opt out of receiving phone calls or text messages regarding upcoming appointments or incomplete documents. You may access your portal here: https://firmfoundationcounselingllc.clientsecure.me
Help/Customer Support
Text the word HELP for support. You may also contact us directly by phone at +15744021400 or by email at Brooklyn@firmfoundationcounselingllc.com
Liability
We are not responsible for any charges, errors, or delays in SMS delivery or undelivered messages caused by your carrier or third-party service providers.
Also, you have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described about. We will be happy to discuss these situations with you now or as they arise. If you have any questions regarding this notice or our health information privacy policies, please contact Info@firmfoundationcounselingllc.com
About the therapists:
Brooklyn Spirito is a licensed mental health counselor in the state of Indiana
Abby Brenner is a licensed social worker in the state of Indiana under supervision of Courtney Nowicki
Bryanna Ruge is a licensed mental health counselor in the state of Indiana
Courtney Nowicki is a licensed clinical social worker in the state of Indiana
Diana Yoder is a licensed mental health counselor in the state of Indiana and Florida
Karina Engles is a licensed social worker in the state of Indiana and is under the supervision of Courtney Nowicki
Paul Engles is a licensed social worker in the state of Indiana and is under the supervision of Courtney Nowicki
Madeline Berger is a licensed social worker in the state of Indiana and is under the supervision of Courtney Nowicki
Doris Mathew is a licensed mental health counselor in the state of Indiana
Elise Walter is a licensed mental health counselor in the state of Indiana
Morgan Jones is a licensed mental health counselor associate in the state of Indiana under supervision of Brooklyn Spirito
Tara Tuttle is a licensed mental health counselor in the state of Indiana
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