NOTICE OF PRIVACY PRACTICES

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EFFECTIVE DATE OF THIS NOTICE: 01/01/2024

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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.

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SIRONA MENTAL WELLNESS, LLC (“SIRONA”) is required to maintain the privacy of Protected Health Information (“PHI”) and to provide individuals with notice of our legal entities and privacy practices with respect to PHI.

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I. OUR PLEDGE REGARDING HEALTH INFORMATION: SIRONA understands that health information about you and your health care is personal. SIRONA is committed to protecting health information about you. SIRONA creates a record of the care and services you receive. This record ensures that SIRONA healthcare providers provide you with quality care and to comply with certain legal requirements. This notice applies to all the records of your care generated by this mental health care practice. This notice will tell you about the ways in which SIRONA may use and disclose health information about you. This notice also describes your rights to the health information about you that SIRONA retains, and describes certain obligations SIRONA has regarding the use and disclosure of your health information. SIRONA is required by law to:

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• Make sure that protected health information that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• SIRONA can change the terms of this Notice, and such changes will apply to all information that SIRONA has about you. The new Notice will be available upon request, in the office, and on the Sirona Mental Wellness website.

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II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that SIRONA uses and discloses health information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.

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For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment, or health care operations. SIRONA may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

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Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

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Lawsuits and Disputes: If you are involved in a lawsuit, SIRONA may disclose health information in response to a court or administrative order. SIRONA may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

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III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

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1. Psychotherapy Notes. SIRONA does maintain “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

   1. For use in treating you.

   2. For use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

   3. For use in defending SIRONA in legal proceedings instituted by you.

   4. For use by the Secretary of Health and Human Services to investigate SIRONA’s compliance with HIPAA.

   5. Required by law and the use or disclosure is limited to the requirements of such law.

   6. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

   7. Required by a coroner who is performing duties authorized by law.

   8. Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes. SIRONA will not use or disclose your PHI for marketing purposes.

3. Sale of PHI. SIRONA will not sell your PHI in the regular course of my business.

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IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, SIRONA can use and disclose your PHI without your Authorization for the following reasons:

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1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one intervention/treatment versus those who received a different intervention/treatment for the same condition. We may disclose PHI about you to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.

10. Appointment reminders and health related benefits or services. SIRONA may use and disclose your PHI to contact you to remind you that you have an appointment. SIRONA may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that are offered

11. Business Associates. There are some services provided in Sirona through our business associates. For example, we may use a copy service to make copies of your medical record. When we hire companies to perform these services, we may disclose your PHI to these companies so that they can perform the job we have asked them to perform. To protect your PHI, however, we require the business associate to appropriately safeguard your PHI.

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V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

1. Disclosures to family, friends, or others. SIRONA may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

2. Electronic Health Information Exchange (HIE). We may participate in certain HIEs that permit healthcare providers or other healthcare entities, such as your health plan or health insurer, to share your PHI for treatment, payment and other purposes permitted by law, including those described in this Notice. You may ask that your PHI no longer be contributed to an HIE by sending your request to the Privacy Officer at the address below. Please include your name, medical record number and date of birth or address. We will use reasonable efforts to limit the sharing of PHI in HIEs if you opt out. Opting out will not recall your PHI that has already been shared, nor will it prevent access to PHI about you by other means, e.g., request by your individual providers.

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VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask SIRONA not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if your SIRONA healthcare provider believes it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How We Send PHI to You. You have the right to ask SIRONA to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.

4. 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 we have about you. SIRONA will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost-based fee for doing so.

5. The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. SIRONA will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. SIRONA will provide the list to you at no charge, but if you make more than one request in the same year, SIRONA will charge you a reasonable cost-based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that SIRONA corrects the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

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For More Information or to Report a Problem

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If you have questions or would like additional information about SIRONA’s privacy practices, you may call SIRONA at (513) 991-7007 or by mailing request: Sirona Mental Wellness, 8200 Beckett Park Drive, Suite 111, West Chester, OH 45069. We will accommodate all reasonable requests. If you believe your privacy rights have been violated, you can file a complaint with our Office or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

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The Notice of Privacy Practices is subject to change, and you may obtain a copy of the revised notice at www.sironamentalwellness.com or by or calling (513) 991-7007. If you have any questions about our “Notice of Privacy Practices,” please call (513) 991-7007.