Notice of Privacy Practices

I. Our Pledge Regarding Health Information

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from our clinicians. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Evergreen Counseling and Wellness, and it is followed by every clinician and staff member of our practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of our legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• Notify you if a breach occurs that may have compromised the privacy or security of your information.

We can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website.

II. How We May Use and Disclose Health Information About You

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment, Payment, or Health Care Operations. Federal privacy rules (regulations) allow health care providers who have a direct treatment relationship with the client to use or disclose the client’s personal health information without the client’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. We 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.

• Treatment. 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. 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 client for health care from one health care provider to another.
• Payment. For example, we may use your information to process payment for your sessions and to prepare a superbill you may choose to submit to your insurance.
• Health Care Operations. For example, we may use your information for clinical supervision and quality review of our clinicians’ work, and for scheduling your appointments.

Lawsuits and Disputes. If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about you 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.

III. Certain Uses and Disclosures Require Your Authorization

1.Psychotherapy Notes. Our clinicians do keep “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:

a.For the clinician’s use in treating you.

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

c.For use in defending ourselves in legal proceedings instituted by you.

d.For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA.

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

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

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

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

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

3.Sale of PHI. We will not sell your PHI.

4.Other Uses and Disclosures. Other uses and disclosures not described in this notice will be made only with your written authorization. You may revoke an authorization at any time in writing, except to the extent we have already acted on it.

IV. Certain Uses and Disclosures Do Not Require Your Authorization

Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:

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 our preference is to obtain an Authorization from you before doing so.

5.For law enforcement purposes, including reporting crimes occurring on our 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 clients who received one form of therapy versus those who received another form of therapy for the same condition.

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 our 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. We may use and disclose your PHI to contact you to remind you that you have an appointment. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.

Where Colorado law gives your health information more protection than federal law, we follow Colorado law.

V. Certain Uses and Disclosures Require You to Have the Opportunity to Object

1.Disclosures to family, friends, or others. We 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.

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 us 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 we believe 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 us 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. We 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 us with an Authorization. We 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. We will provide the list to you at no charge, but if you make more than one request in the same year, we 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 we correct 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 to 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. This Notice is also posted on our website at www.therapyevergreen.com/notice-of-privacy-practices.

8.The Right to Be Notified of a Breach. You have the right to be notified if a breach occurs that may have compromised the privacy or security of your unsecured PHI.

9.The Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with Evergreen Counseling and Wellness by contacting our Privacy Officer (below). You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, online at https://ocrportal.hhs.gov/, by email at OCRComplaint@hhs.gov, or by mail to Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201. We will not retaliate against you for filing a complaint.

VII. Special Authorizations

Certain categories of information have extra protections by law, and thus require special written authorizations for disclosures.

1.Psychotherapy Notes: Our clinicians may keep and maintain “Psychotherapy Notes,” which may include but are not limited to notes a clinician makes about your conversation during a private, group, joint, or family counseling session, which are kept separately from the rest of your record. These notes are given a greater degree of protection than PHI. These are not considered part of your “client record.” We will obtain a special authorization before releasing your Psychotherapy Notes.

2.HIV Information: Special legal protections apply to HIV/AIDS related information. We will obtain a special written authorization from you before releasing information related to HIV/AIDS.

3.Alcohol and Drug Use Information: Special legal protections apply to information related to alcohol and drug use and treatment. We will obtain a special written authorization from you before releasing information related to alcohol and/or drug use/treatment.

Substance Use Disorder Records (42 CFR Part 2). If we receive records from a substance use disorder treatment program protected by 42 CFR Part 2, you have the right to adequate notice of how those records may be used and disclosed and of our legal duties regarding them. Those records receive the extra protections described in this section and generally will not be used or disclosed for treatment, payment, or health care operations without your written consent. They will not be used or disclosed in any civil, criminal, administrative, or legislative proceeding against you without your written consent or a court order, issued after notice and an opportunity to be heard and accompanied by a subpoena or other legal requirement compelling disclosure. If we disclose these records to someone who is not subject to HIPAA, the recipient may further use or disclose them without HIPAA’s protections. We do not use these records for fundraising, and we do not conduct fundraising.

You may revoke all such authorizations to release information (PHI, Psychotherapy Notes, HIV information, and/or Alcohol and Drug Use Information) at any time, provided each revocation is in writing and signed by you. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, the law provides the insurer the right to contest the claim under the policy.

As a covered entity under the Privacy and Security Rules, we are required to reasonably safeguard PHI from impermissible uses and disclosures. Safeguards may include, but are not limited to the following:

1.Not leaving client records unattended where third parties without a need to know can view them.

2.Any PHI received as an employee, intern, or volunteer about a client or potential client may not be used or disclosed for non-work purposes or with unauthorized individuals. Evergreen Counseling and Wellness may only use and disclose such PHI as described above.

3.When speaking with a client about his or her PHI where third parties could possibly overhear, the conversation will be moved to a private area.

4.Seeking legal counsel in uncertain situations and/or incidences.

5.Obtaining a Business Associates Agreement with those third parties that have access to and/or store client information. Some of the functions of the practice may be provided by contracts with business associates. For example, some of the billing, legal, auditing, and practice management services may be provided by contracting with outside entities to perform those services.

6.Implementing FAX security measures.

7.Obtaining your consent prior to sending any PHI by unsecure electronic transmissions.

8.Providing information on our electronic record-keeping.

VIII. Your Choices

For certain health information, you can tell us (verbal authorization) your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to your clinician, tell us what you want us to do, and we will follow your requests. We may request you sign a separate document if you authorize us to share certain PHI. You may revoke that authorization at any time for future disclosure.

In these cases, you have both the right and choice to tell Evergreen Counseling and Wellness to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest and for your care/treatment. We may also share your information when needed to lessen a serious and imminent threat to public health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

IX. Privacy Officer

For questions about this notice, to exercise any of your rights, or to file a complaint with our practice, contact:

Valery Krieg, MSW, LCSW, Privacy Officer
Evergreen Counseling and Wellness
32135 Castle Court, Suite 208B, Evergreen, CO 80439
(720) 779-2250 · help@therapyevergreen.com

X. Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

This notice is effective October 30, 2026.