Christian Counseling in-person and online for women in Pennsylvania

Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

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Our Uses and Disclosures

We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government
requests
• Respond to lawsuits and legal actions

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Your Rights

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When it comes to your health information, you have certain rights. This section explains your rights
and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health
information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your
request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete.

Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send
mail to a different address.
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our
operations. We are not required to agree to your request, and we may say “no” if it would affect
your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that
information for the purpose of payment or our operations with your health insurer. We will say
“yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six
years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care
operations, and certain other disclosures (such as any you asked us to make). We’ll provide one
accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one
within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice
electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that
person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information
on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil
Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-
877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

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Your Choices

For certain health information, you can tell us 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 us. Tell us what
you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

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

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. We may also share your
information when needed to lessen a serious and imminent threat to 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

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Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

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We can use and share your health information to run our practice, improve your care, and contact
you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services

We can use and share your health information to bill and get payment from health plans or other
entities.
Example: We give information about you to your health insurance plan so it will pay for your
services.

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How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to
the public good, such as public health and research. We have to meet many conditions in the law before
we can share your information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html .

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an
individual dies.

Address workers’ compensation, law enforcement, and other government requests

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We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective
services

Respond to lawsuits and legal actions
 

We can share health information about you in response to a court or administrative order, or in
response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health
information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or
security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of
it.
• We will not use or share your information other than as described here unless you tell us we can
in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if
you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html .

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 web site.

Other Instructions for Notice

• Effective Date of this Notice: 7/8/2023
• Amy C. Grimes, LSW; agrimes@pathwayscs.com; 717-263-7758 x709
• We never market or sell your personal information.
• We use some 3rd party services for scheduling, documentation, document sharing, payment processing, and email/phone communication. These services use security measures that provide protection and privacy of your health information. We will only share information about you that is necessary for the third party to provide the requested service. These companies are prohibited from retaining, sharing, buying, selling, storing or using your personally identifiable information for any secondary purposes.