THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. RIVERVIEW COUNSELING SERVICES’ 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. Your therapist creates a record of the care and services you receive. The therapist needs 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 Riverview Counseling Services.

This notice will tell you about the ways in which health information may be used and disclosed, describe your rights to the health information kept, and outline certain obligations.

Riverview Counseling Services is required by law to:

1. Make sure that protected health information (“PHI”) that identifies you is kept private.

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

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

4. The terms of this Notice can change, and such changes will apply to all information. The new Notice will be available upon request, in each Riverview Counseling Services office, and on the website.

II. HOW HEALTH INFORMATION ABOUT YOU IS USED AND DISCLOSED:

The following categories describe different ways health information is used or disclosed. For each category of uses or disclosures, an explanation and examples are provided. Not every use or disclosure in a category will be listed. However, all of the permitted uses and disclosures of health information will fall within one of the categories.

For Treatment, Payment, or Health Care Operations: Federal privacy rules and 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. Disclosure of your protected health information may also occur for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinicianwere 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 patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, disclosure of health information can occur in response to a court or administrative order. Health information may be disclosed 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.

Substance Use Disorder (SUD) Records (42 CFR Part 2): If records are received, created, or maintained regarding substance use disorder diagnosis, prognosis, or treatment that are protected under federal law (42 CFR Part 2), those records receive heightened privacy protections. Subject to 42 CFR Part 2, information in those records cannot be used or shared in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your written consent or (2) a specialized court order and a subpoena.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes. Therapists 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 therapist to use in treating you.

b. For the therapist to 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 the therapist to use in defending themselves in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate 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. Riverview Counseling Services and your therapist will not use or disclose your PHI for marketing purposes.3. Sale of PHI. Riverview Counseling Services and your therapist will not sell your PHI in the regular course of business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.

Subject to certain limitations in the law, your PHI can be used and disclosed 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 the 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 form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including and 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 the preference is to obtain an Authorization from you, PHI may be provided in order to comply with workers’ compensation laws.

10. Appointment reminders and health-related benefits or services. PHI may be used or disclosed to contact you to remind you that you have an appointment. Your PHI may also be used to tell you about treatment alternatives, or other health care services or benefits offered.

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

Disclosures to family, friends, or others. PHI may be provided 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 emergencies.

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 Riverview Counseling Services and your therapist not to use or disclose certain PHI for treatment, payment, or health care operations purposes. There is no requirement toagree to your request, and it may be denied if there is concern 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 PHI is sent to you. You have the right to ask for a specific form of contact (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. 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 Made. You have the right to request a list of instances in which your therapist has disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list will include disclosures made in the last six years unless you request a shorter time. That list will be provided to you at no charge, but if you make more than one request in the same year, there will be 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 it be corrected with the existing information or add the missing information. If that request is denied, you will be notified with an explanation 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.

8. The Right to Request Restrictions on Substance Use Disorder (SUD) Disclosures. You have the right to request that we restrict disclosures of your SUD records for treatment, payment, or health care operations if you pay for your services entirely out-of-pocket.

9. The Right to an Accounting of Disclosures for SUD Records. If your SUD records are disclosed for treatment, payment, or health care operations through an electronic health record, you have the right to receive an accounting of those disclosures made within the 3 years prior to your request.

VII. COMPLAINTS AND CONTACT INFORMATION

If you believe your privacy rights have been violated, or if you have questions about this Notice, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. You will not be penalized or retaliated against for filing a complaint.

To file a complaint or ask questions, please contact our designated Privacy Official:

• Name/Title: Sarah Hitchings or her designee

• Phone: 630-587-3777

• Email: sarahhitchings@riverviewcounselingservices.com

• Address: 111 East Main Street, Saint Charles, IL 60174-1948

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing this document, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

Signature:

I have received HIPAA Notification