NOTICE OF PRIVACY PRACTICES WORTHINGTON BEHAVIORAL SERVICES LLC

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.

Effective Date: September 13, 2022

If you have any questions about this notice or if you need more information, please contact the company owner, Jessica Worthington.

Jessica Worthington, MA, BCBA

Mailing Address: PO Box #170845, Milwaukee, WI 53217-4504

Telephone: (414) 454-9093

Fax: (414) 888-5844

About This Notice

We are required by law to maintain the privacy of Protected Health Information and to give you this Notice explaining our privacy practices regarding that information. You have certain rights – and we have certain legal obligations – regarding the privacy of your Protected Health Information, and this Notice also explains your rights and our obligations. We are required to abide by the terms of the current version of this Notice.

What Is Protected Health Information?

“Protected Health Information” is information that individually identifies you and that we create or get from you or from another health care provider, health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health or conditions, (2) the provision of health care to you, or (3) the past, present, or future payment of your health care.

1. How We May Use and Disclose Your Protected Health Information

You will be asked to sign a consent form. Once you have consented to use and disclosure of your Protected Health Information for treatment, payment, and health care operations by signing the consent form, your ABA provider will use or disclose your Protected Health Information as described in this Section 1. Your Protected Health Information may be used and disclosed by your ABA provider, our company staff, and others outside of our company that are involved in your care and treatment for the purpose of providing health care services to you.

We may use and disclose your Protected Health Information in the following circumstances:

For Treatment: We may use or disclose your Protected Health Information to give you medical treatment or services and to manage and coordinate your medical care. For example, your Protected Health Information may be provided to a physician or other health care provider (e.g., a specialist or therapist) to whom you have been referred to ensure that the physician or other health care provider has the necessary information to diagnose you, treat you, or provide you with a service. We may also disclose your Protected Health Information to another ABA provider or health care provider who, at the request of your ABA provider, becomes involved in your care by providing assistance to your ABA provider with your diagnosis or treatment.

For Health Care Operations: We may use and disclose Protected Health Information for the health care operations of Worthington Behavioral Services LLC. We may use your Protected Health Information to internally review the quality of the treatment and services you receive and to evaluate the performance of our employees in caring for you. As part of health care operations at Worthington Behavioral Services LLC we also may disclose information to BCBAs, BCaBAs, RBTs, or other therapy team members and other authorized personnel for educational and learning purposes. For example, we may disclose your Protected Health Information to BCBA/BCaBA/RBT Trainees who serve clients at our company.

We may also use or disclose the Protected Health Information, as necessary, to provide you with information about possible treatment options or alternatives or health-related benefits and services that may be of interest to you.

Minors: We may disclose the Protected Health Information of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object

As Required by Law: We will disclose Protected Health Information about you when required to do so by international, federal, state, or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

To Avert a Serious Threat to Health or Safety: We may use and disclose Protected Health Information when necessary to prevent a serious threat to your health or safety or to the health or safety of others. But we will only disclose the information to someone who may be able to help prevent the threat.

Business Associate: We may disclose Protected Health Information to our business associates who perform functions on our behalf or provide us with services if the Protected Health Information is necessary for those functions or services. For example, we may use another company or private provider to provide consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your Protected Health Information.

Military Activity and National Security: If you are a member of the armed forces, we may disclose Protected Health Information as required by military command authorities. We also may disclose Protected Health Information to the appropriate foreign military authority if you are a member of a foreign military. If you are involved with military, national security or intelligence activities or if you are in law enforcement custody, we may disclose your Protected Health Information to authorized officials so they may carry out their legal duties under the law.

Workers’ Compensation: We may use or disclose Protected Health Information for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.

Public Health Risks: We may disclose Protected Health Information for public health activities. This includes disclosures to: (1) a person subject to jurisdiction of the Food and Drug Administration (“FDA”) for purposes related to the quality, safety or effectiveness of an FDA-regulated product or activity; (2) prevent or control disease, injury or disability; (3) report births and deaths; (4) report child abuse or neglect; (5) report reactions to medications or problems with products; (6) notify people of recalls of products they may be using; and (7) a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. We may also disclose Protected Health Information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Abuse. Neglect, or Domestic Violence: We may disclose Protected Health Information to the appropriate government authority if we believe a patient/client has been the victim of abuse, neglect, or domestic violence. Such disclosures will be made consistent with the requirements of applicable federal and state laws.

Health Oversight Activities: We may disclose Protected Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Data Breach Notification Purposes: We may use or disclose you Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

Legal Proceedings: If you are involved in a lawsuit or a dispute, we may disclose Protected Health Information in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your Protected Health Information to defend ourselves in the event of a lawsuit.

Law Enforcement: We may disclose Protected Health Information, so long as applicable legal requirements are met, for law enforcement purposes.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your Protected Health Information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to health or safety of a person or the public. We may also disclose Protected Health Information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Coroners. Medical Examiners, and Funeral Directors: We may disclose Protected Health Information to a coroner, medical examiner, or funeral director so that they can carry out their duties.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose Protected Health Information to the correctional institution or law enforcement official if the disclosure is necessary (1) for the institution to provide you with health care; (2) to protect your health and safety of the health and safety of others; or (3) the safety and security of the correctional institution.

Uses and Disclosures That Require Us to Give You an Opportunity to Object and Opt Out

Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgement.

Emergencies: We may use or disclose your Protected Health Information in an emergency treatment situation. If this happens, your ABA provider shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment.

Communication Barriers: We may use and disclose your Protected Health Information if your ABA provider attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the ABA provider determines, using professional judgement, that you intend to consent to use or disclosure under the circumstances.

Disaster Relief: We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object such a disclosure whenever we practicably can do so.

Your Written Authorization is Required for Other Uses and Disclosures

The following uses and disclosures of your Protected Health Information will be made only with your written authorization:

1. Most uses and disclosures of psychotherapy notes;

2. Uses and disclosures of Protected Health Information for marketing purposes; and

3. Disclosures that constitute the sale of your Protected Health Information.

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our company owner and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

2. Your Rights Regarding Your Protected Health Information

You have the following rights, subject to certain limitations, regarding your Protected Health Information:

Right to Inspect and Copy: You have the right to inspect and copy Protected Health Information that may be used to make decisions about your care. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and Protected Health Information that is subject to law that prohibits access to Protected Health Information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our company owner if you have any questions about access to your health record. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records: If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach: You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

Right to Request Amendments: If you feel that the Protected Health Information we have is incorrect or incomplete, you may ask us to amend the information for as long as we maintain this information. A request for amendment must be made in writing to the company owner at the address provided at the beginning of this Notice and it must tell us the reason for your request. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

Right to an Accounting of Disclosures: You have the right to ask for an “accounting of disclosures” which is a list of the disclosures we made of your Protected Health Information. This right applies to disclosures for purposes other than treatment or health care operations as described in this Notice. It excludes disclosures we may have made to you, for a resident directory, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions, and limitations. Additionally, limitations are different for electronic health records.

Right to Request Restrictions: You have the right to request a restriction or limitation on the Protected Health Information we use or disclose for treatment or health care operations. You also have the right to request a limit on the Protected Health Information we disclose about you to someone who is involved in your care, like a family member or friend. To request a restriction on who may have access to your Protected Health Information, you must submit a written request to the company owner. Your request must state the specific restriction requested and to whom you want the restriction to apply. If your ABA provider believes it is in your best interest to permit use and disclosure of your Protected Health Information, your Protected Health Information will not be restricted. If your ABA provider does agree to the requested restriction, we may not use or disclose your Protected Health Information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your ABA provider.

Right to Request Confidential Communications: You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address or call you only at your work number. You must make any such request in writing to our company owner. You must specify how or where we are to contact you. We will accommodate all reasonable requests. We will not ask you the reason for your request.

Right to a Paper Copy of this Notice: You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time.

How to Exercise Your Rights

To exercise your rights described in this Notice, send your request, in writing, to our company owner at the address listed at the beginning of this Notice. We may ask you to fill out a form that we will supply. To exercise your right to inspect and copy your Protected Health Information, you may also contact your ABA provider directly. To get a paper copy of this Notice, contact our company owner by phone or email.

Changes to this Notice

We reserve the right to change this Notice. We reserve the right to make the changed Notice effective for Protected Health Information we already have as well as for any Protected Health Information we create or receive in the future. A copy of our current Notice is posted on our website.

3. Complaints

You may file a complaint with us or with the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated.

To file a complaint with us, contact our company owner, Jessica Worthington, at the address listed at the beginning of the Notice. All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of the suspected violation. There will be no retaliation against you for filing a complaint.

To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call (202) 619-0257 (or toll free (877) 696-6775) or go to the website of the Office for Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. There will be no retaliation against you for filing a complaint.