NOTICE of PRIVACY PRACTICES

This form is required to be updated each year.

WELCOME to HEARTS at HOME COUNSELING

This form helps you understand how your private health information may be used or shared. If anything is unclear, feel free to ask questions. This agreement is for you—so you feel safe and informed.

What is a PRIVACY NOTICE?

This notice, sometimes called a HIPAA form, explains your rights and how we manage your PHI or Protected Health Information. PHI includes things like your name, date of birth, and private information that you share in therapy. HIPAA stands for the Health Insurance Portability and Accountability Act. This law makes sure your information is kept private.

We are required by law to give you this notice. When you sign this form, you show that you understand how we use and protect your information. If the law changes, or if your rights change, we’ll update this form and give you the new version.

RIGHTS to your Protected Health Information:

1.     View records. You can ask for a paper or electronic copy.

2.     Request a correction. If something looks wrong, you can ask us to fix it. We may say no, but we’ll explain why.

3.     Request private communication. You can ask us to contact you a certain way—like by phone only or by secure email only.

4.     Limit what we share. You can ask us not to share some things. We may say no if it affects your care.

5.     Keep information from your insurance. If you pay in full, you can ask us not to tell your health plan.

6.     See who we’ve shared with. You can ask for a list once a year.

7.     Get a copy of this notice. Just ask—we’ll print it for you.

8.     Pick someone to act for you. If someone is your legal guardian or has medical power of attorney, they can make choices for you.

9.     File a complaint. If you believe your rights were violated, you can file a complaint with us or with the U.S. Department of Health and Human Services. We won’t retaliate or punish you for doing so.

Hearts at Home Counseling
169 West 2710 South Circle, Suite 203-A2
Saint George, UT 84790
Lea Frances-Poll
Phone: 435-288-1411

U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 877-696-6775
Website: www.hhs.gov/ocr/privacy/hipaa/complaints

ALLOWED USE of Protected Health Information

  • To make treatment decisions. You can give written permission for us to communicate with other medical providers.

  • To run our business. We use PHI to manage the practice, improve services, and contact you.

  • To get paid. We may send PHI to your insurance or payment source.

PERMISSION to SHARE Protected Health Information

We’ll get your written permission before we:

  • Share your psychotherapy notes

  • Use your information for marketing

  • Sell your PHI

You can change your mind at any time by letting us know in writing.

SPECIAL CIRCUMSTANCES

There are times we must or may share your information without asking for permission first, including:

Public health and safety. To report disease or stop harm.

  • Government investigations. Like audits and inspections.

  • Court orders or legal reasons. When the law says we have to.

  • Law enforcement. To find a missing person or report a crime.

  • Emergencies. To prevent serious danger.

  • Abuse or neglect. To help someone in danger.

  • Military or national security. If required by federal law.

  • Organ donation or funeral services. When legally allowed.

  • Research. If the project is approved and your privacy is protected.

  • Others who help us. Like billing or tech support companies that work for us.

OUR RESPONSIBILITIES

We are required to:

  • Keep your PHI private and safe

  • Tell you if your information is ever breached

  • Follow the rules in this notice

  • Update this notice if the law or rules change

You can always get a copy at heartsathomecounseling.com/notice-of-privacy-practices

YOUR VOICE MATTERS

If something doesn’t feel right, please speak up. If you ever feel uncomfortable or believe I’ve done something wrong, you can let me know—or contact the Utah state licensing board or the U.S. Department of Health and Human Services.

  • Utah Division of Professional Licensing (DOPL): 801-530-6628, https://dopl.utah.gov

AGREEMENT

This agreement helps us work well together. Please let me know if you have questions at any time.

By signing this form, you confirm that you have read and understand all sections of this document and agree to the information provided.

This NOTICE of PRIVACY PRACTICES is effective on January 1, 2025.