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.

This privacy notice will help you understand your rights and the obligations of Born Counseling and Consulting, LLC (BCC) in protecting your privacy. It is our policy and requirement by law to keep your protected health information confidential. This notice tells you who can look at your information without your permission, and who is not allowed to look at your information unless you give them permission. This notice also tells you what our legal duties are and the rules and standards we have in place to protect your health information. It is a government rule that we give you this privacy notice and have you sign that you received it and understand what it means.

What is protected health information? Protected health information is any personal information that can identify you. Your protected health information is kept in your designated record set. This record set is maintained by BCC and contains information about your past, present, or future, including health conditions, the provision of behavioral health care to you, or payment for behavioral health care.

Your rights regarding your protected health information If you have requests or question on the use of any of your rights listed below, you can contact our main office at 602-517-0119 by sending a letter to BCC at 34406 N. 27th Drive, Building 6 Suite 104, Phoenix AZ, 85085 or by contacting the BCC staff coordinating your services.

1. Right to Inspect and Copy Protected Health Information: You have the right to inspect and/or obtain a copy, summary, or explanation of your protected health information. To do so, please make your request in writing. Your request will then be forwarded to the Clinical Director. At times, it may be determined that reviewing or receiving certain documents would be detrimental to your well-being, but you would have the right to appeal such a decision. Once approved, the Clinical Director will arrange a time to meet with you to inspect your records or to give you a free copy. Free copies may be requested once during a 12 month period of time, and we may charge a reasonable cost-based fee for additional copies.

2. Right to Request Restrictions: You have the right to request that we restrict the use or disclosure of your protected health information. We will do our best to accommodate your requests, although we will not be able to limit the uses and disclosures that are required by law. Please make this request in writing.

3. Right to Request Conditions on Providing Confidential Communications: You have the right to request that we not communicate with you in typical ways by filling out a Confidential Communication request to restrict the methods we might use to communicate with you.

4. Right to Request an Amendment: You have the right to request a change be made to your records for as long as we maintain your records. Please make such requests in writing, and include the reasons for your request. We will review the documents with you and determine if the records should be amended. There may be a time that BCC would not make the changes you requested, such as if the requested change is for a record that was not created by us or is determined to be accurate and complete.

5. Right to Receive an Accounting of Disclosures: BCC maintains a list of people who are required to access your records without your knowledge. You have the right to receive an accounting of all times we have disclosures of your behavioral health information without your consent. Please make your request in writing, and forward it to your BCC staff.

6. You have the right to receive this notice: You have the right to receive a paper copy of this notice and/or an electronic copy by email upon request.

Uses and disclosures relating to treatment, payment, or behavioral health care operations BCC routinely discloses your protected health information for purposes of providing support, arranging for payment or funding of services, and behavioral health care operations. Generally, we may use or disclose your protected health information as follows:

1. For providing support: We may use or disclose your protected health information to provide, coordinate, or manage your support services. For example, your protected health information will be shared among members of your team. Your protected health information may also be shared with outside organizations performing other services relating to your support services.

2. For payment: We may use or disclose your protected health information in order to bill and collect payment for your behavioral health care services.

3. For behavioral health care operations: We may use or disclose your protected health information for behavioral health care operations. For example, members of the team may share protected health information to assess the care and outcomes in your case. We may use your protected health information in reviewing and improving the quality and efficiency of our services. We may use or disclose your protected health information for competency assurance activities, including performance evaluation, credentialing, and licensing.

Uses and disclosures of protected health information not requiring authorization Unless otherwise prohibited by law, we may use or disclose your protected health information without your consent or authorization in these cases:

1. When required by law: We may use and disclose protected health information without your permission when required by law.

2. For public health activities: We may disclose protected health information to public health authorities authorized by law to collect or receive such information for: • Preventing or controlling disease, injury, or disability • To receive reports of child abuse and neglect; • Organizations subject to Food and Drug Administration, • Individual who may have contracted or been exposed to a communicable disease when notification is authorized by law and • Employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury.

3. Victims of Abuse, Neglect or Domestic Violence: In certain circumstances, BCC may disclose protected health information to appropriate government authorities regarding victims of abuse, neglect or domestic violence.

4. For health oversight activities: We may disclose protected health information to a health oversight agency for activities authorized by law. These oversight activities may include monitoring, inspections, investigations, inspections, human rights committees, and licensure.

5. Judicial and Administrative Proceedings: BCC may disclose protected health information in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individual or a protected order are provided.

6. Law Enforcement Purposes: BCC may disclose protected health information to law enforcement officials for law enforcement purposes under the following six circumstances and are subject to specified conditions: • As required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests • To identify or find a suspect, fugitive, material witness, or missing person • In response to a law enforcement official’s request for information about a victim or suspected victim of a crime • To alert law enforcement of a person’s death if BCC suspects that criminal activity caused the death • When BCC believes that protected health information is evidence of a crime that occurred on its premises and • In a medical emergency not occurring on its premise, when necessary to inform law enforcement about the commission and nature of a crime.

7. Decedents: We may disclose protected health information relating to an individual’s death including information to coroners, medical examiners or funeral directors, and organ procurement organizations relating to organ, eye, or tissue donations or transplants.

8. Research: In certain limited circumstances, we may disclose your protected health information for research purposes. BCC may also disclose, without your written permission, a limited data set of protected health information for research purposes.

9. To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose protected health information as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.

10. For specific government functions: We may disclose protected health information for essential government functions. Such functions include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protected the health and safety of inmates or employees in a jail or prison, and determining eligibility for or conducting enrollment in certain government benefit programs.

11. Workers’ Compensation: We may disclose protected health information as authorized by, and to comply with, workers’ compensation laws and other similar programs providing benefits for work-related injuries or illnesses.

12. Business Associate: We may disclose your protected health information to a business associate in order for that entity to perform a function on our behalf. We must have in place an agreement from the business associate that it will extend the same degree of privacy protection to your information that we must apply to your information.

Uses and disclosures requiring you to have an opportunity to agree or object In the following situations, we may disclose a limited amount of your protected health information, if we inform you about the disclosure in advance and you do not object, as long as the disclosure is not otherwise prohibited by law.

1. To families, friends or others involved in your care: We may share with these people information directly related to their involvement in your care, or payment for your care. You will be provided with the opportunity to agree or object. In the event that you are incapacitated or in an emergency situation, we will use professional judgment to decide if protected health information will be disclosed.

2. Disaster Relief: In the use of professional judgment, BCC may disclose protected health information to a public or private entity authorized to help in disaster relief efforts for the purpose of coordinating with such entity your location, general condition, or death.

3. Limited Data Set: A limited data set is protected health information from which certain specified direct identifiers of the individuals and their relatives, household members and employer have been removed. A limited data set may be used and disclosed for research, health care operations and public health purposes.

4. Personal Representative: We may disclose protected health information to persons acting as a personal representative for you.

Other uses and disclosures All other uses and disclosures of your protected health information will only be made with your written permission and you may revoke that permission at any time.

How to File a Complaint if You Believe Your Privacy Rights Have Been Violated If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below. Your complaint can be in writing or by calling our office.

Born Counseling and Consulting, LLC

34406 N. 27th Drive, Building 6 Suite 104

Phoenix AZ 85085

602-517-0119

You also may write a letter of complaint to the Secretary of the U.S. Department of Health and Human Services. To ask for a complaint form, write to:

US Dept of Health & Human Services Office of Civil Rights 50 United Nations Plaza – Room 322

San Francisco, CA 94102

Attn: Regional Manager Or call for a complaint form at 1-800-368-1019

We will take no retaliatory action against you if you make such complaints.

BCC may change our policies at any time. However, before we make a significant change to our policies, we will change our notice privacy practices and deliver the revised notice to you as required by law. The revised notice will be effective for all protected health information that we maintain at that time. We will not implement any of the changes until the effective date of the change except when required by law.

We are required to abide by all the terms in this notice.