Clinicians’ Policies and Practices to Protect the
Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL, MEDICAL, AND OTHER HEALTH-
RELATED INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
AAA Counseling, LLC (hereafter, AAA) clinicians and their support staff may use or disclose your protected health
information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify
these terms, here are some definitions:
• “PHI” refers to information in your health record that could identify you.
• “Clinician” refers to any mental health professional who provides clinical services. At AAA this includes both
psychiatry staff and psychotherapists/counselors.
• “Treatment, Payment and Health Care Operations”
– Treatment is when your AAA clinician provides, coordinates or manages your health care and other
services related to your health care. An example of treatment would be when the clinician consults with
another health care provider, such as your family physician or another mental health professional.
– Payment is when AAA obtains reimbursement for your healthcare. An example of payment is when
your clinician discloses your PHI to your health insurer to obtain reimbursement for your health care or
to determine eligibility or coverage.
3(HIPAA Notice form cont’d)
– Health Care Operations are activities that relate to the performance and operation of the AAA
office practices. Examples of health care operations are quality assessment and improvement
activities, business-related matters such as audits and administrative services, and case
management and care coordination.
• “Use” applies only to activities within AAA such as sharing, employing, applying, utilizing, examining, and
analyzing information that identifies you.
• “Disclosure” applies to activities outside of AAA such as releasing, transferring, or providing access to
information about you to other parties.
• “Consent” means that you give prior permission. You give AAA consent to handle your PHI as outlined in
this Notice when you sign the Patient Acknowledgement form.
II. Uses and Disclosures Requiring Authorization
Your AAA clinician may use or disclose PHI for purposes outside of treatment, payment, and health care
operations when your appropriate authorization is obtained. An “authorization” is written permission above
and beyond the general consent that permits only specific disclosures. In instances when your clinician is
asked for information for purposes outside of treatment, payment and health care operations, the clinician
will obtain an authorization from you before releasing this information. The clinician will also need to
obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes the
clinician has made about conversations with you during a private, group, joint, or family counseling session,
which have been kept separate from the rest of your medical record. These notes are given a greater degree
of protection than PHI.
You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each
revocation is in writing. You may not revoke an authorization to the extent that (1) the clinician has relied
on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance
coverage, and the law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
Your AAA clinician may use or disclose PHI without your consent or authorization in the following circumstances:
• Child abuse: If the clinician has knowledge of any child who is suffering from or has sustained any wound,
injury, or disability, or physical or mental condition of such a nature as to reasonably indicate that it has
been caused by brutality, abuse, or neglect, the clinician is required by law to report such harm immediately
to STATE Child Protective Services or to the judge having juvenile jurisdiction, or to the office of the
sheriff or the chief law enforcement official of the municipality where the child resides. Also, if the
clinician has reasonable cause to suspect that a child has been sexually abused, the clinician must report
such information, regardless of whether the child has sustained any injury.
• Adult and domestic abuse: If the clinician has reasonable cause to suspect that an adult who is vulnerable
physically, mentally, or emotionally has suffered abuse, neglect, or exploitation, the clinician is required by
law to report such information to the Tennessee Department of Human Services.
• Health oversight: If a complaint is filed against the clinician with the STATE Board of Examiners in
Psychology (or other appropriate state Board of Examiners), the Board has the authority to subpoena
confidential mental health information from me relevant to that complaint.
4(HIPAA Notice form cont’d)
• Judicial or administrative proceedings: If you are involved in a court proceeding and a request
is made for information about the professional services that an AAA clinician has provided you
and/or the records thereof, such information is privileged under state law, and the clinician must
not release this information without your written authorization or a court order. This privilege
does not apply when you are being evaluated for a third party or where the evaluation is court
ordered. The AAA clinician must inform you in advance if this is the case.
• Serious threat to health or safety: If you communicate to your clinician an actual threat of
bodily harm against a clearly identified victim, and the clinician has determined or reasonably
should have determined that you have the apparent ability to commit such an act and are likely to
carry out the threat unless prevented from doing so, the clinician is required to take reasonable
care to predict, warn of, or take precautions to protect the identified victim from your violent
behavior.
• Workers' compensation: If you file a worker's compensation claim, and the clinician is seeing
you for treatment relevant to that claim, the clinician must, upon request, furnish to your
employer or insurer, and to you, a complete report as to the claimed injury, the effect upon you,
the prescribed treatment, and estimate of duration of hospitalization, if any, and a statement of
charges.
IV. Patient's Rights and Clinician’s Duties
Patient’s Rights:
• Right to Request Restrictions You have the right to request restrictions on certain uses and
disclosures of PHI about you. However, the RCPS clinician is not required to agree to a restriction
that you request.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations –
You have the right to request and receive confidential communications of PHI by alternative means
and at alternative locations. (For example, you may not want a family member to know that you are
seeing a clinician. Upon your request, your bills will be sent to another address.)
• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in
RCPS’s mental health and billing records used to make decisions about you for as long as the PHI is
maintained in the record. On your request, the RCPS clinician will discuss with you the details of the
request process.
• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is
maintained in the record. The clinician may deny your request. On your request, the clinician will
discuss with you the details of the amendment process.
• Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI
regarding you. On your request, the clinician will discuss with you the details of the accounting
process.
• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from RCPS upon
request, even if you have agreed to receive the notice electronically.
Clinician’s Duties:
• RCPS is required by law to maintain the privacy of PHI and to provide you with a notice of its legal
duties and privacy practices with respect to PHI.
• RCPS reserves the right to change the privacy policies and practices described in this notice. Unless
RCPS notifies you of such changes, however, RCPS is required to abide by the terms currently in
effect.
• If RCPS revises its policies and procedures, RCPS will notify you by mail, phone, fax, or e-mail.
5(HIPAA Notice form cont’d)
V. Questions and Complaints
If you have questions about this notice, disagree with a decision an AAA clinician makes about access to your
records, or have other concerns about your privacy rights, you may contact the AAA Privacy Officer at xxx-xxx-
xxxx.
If you believe that your privacy rights have been violated and wish to file a complaint with the AAA office, you
may send your written complaint to Privacy Officer, AAA, STREET ADDRESS, CITY, STATE, ZIP. You may
also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. AAA’s
Privacy Officer can provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. AAA will not retaliate against you for exercising your right to
file a complaint.
VI. Effective Date and Changes to Privacy Policy
This notice will go into effect on DD/MM/YYYY.
AAA reserves the right to change the terms of this notice and to make the new notice provisions effective for all
PHI maintained by AAA. AAA will notify you by mail, phone, fax, or e-mail of the revision of notice and make
the revised notice available any of its offices. If needed, AAA will also provide a revised notice by mail, e-mail,
or fax. Additionally, the notice will be made available on AAA’s website (WEBSITE ADDRESS).
As of January 1, 2022, this legislation applies to all healthcare providers and facilities operating under the scope of a state-issued license or certification. You’re required to share a specific consent document in addition to a Good Faith Billing Estimate, prior to beginning care.
State-licensed or certified healthcare providers are required to provide a good faith estimate of charges to every new and continuing client who’s either uninsured, or isn’t planning to submit a claim to their insurance for the services they’re seeking. You’re also required to inform every uninsured or self-pay client of their right to receive a good faith estimate.
Link to details on No Surprises Act:
Copyright © 2026 Amy B Therapy - All Rights Reserved.
Therapy for adults in Virginia and North Carolina
We use cookies to analyze website traffic and optimize your website experience. By accepting our use of cookies, your data will be aggregated with all other user data.