EVERGREEN CLINICAL MENTAL HEALTH COUNSELING LLC
NOTICE OF PRIVACY PRACTICES
Effective Date: January 1, 2026
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. OUR COMMITMENT TO YOUR PRIVACY
Evergreen Clinical Mental Health Counseling (“Evergreen CMHC”) is committed to protecting your protected health information (PHI).
We create and maintain records of the care and services you receive to provide you with quality treatment and to comply with legal and ethical obligations.
This Notice applies to all records of your care generated by Evergreen CMHC.
We are required by law to:
Maintain the privacy and security of your PHI
Provide you with this Notice of our legal duties and privacy practices
Follow the terms of this Notice currently in effect
Notify you in the event of a breach involving unsecured PHI
Update this Notice as required; changes apply to all PHI we maintain
The updated Notice will be available upon request, in-office, and on our website.
II. HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
Without your written authorization, HIPAA allows us to use or disclose PHI for the following purposes:
1. Treatment
We may use or share your information to provide, coordinate, or manage your care.
Examples include:
Consultation with other providers
Coordination of care between services (e.g., counseling, neurofeedback, psychiatry)
Referrals to other professionals
Treatment-related disclosures are not limited to the “minimum necessary” standard because full clinical information may be required for safe and effective care.
2. Payment
We may use or disclose PHI to obtain payment for services.
Examples include:
Billing insurance companies
Submitting claims
Collecting payment for services rendered
3. Health Care Operations
We may use or disclose PHI for internal operations necessary to run our practice.
Examples include:
Quality improvement and assurance
Clinical supervision and case review
Administrative and compliance activities
Business planning and management
4. Legal Proceedings
We may disclose PHI in response to:
Court orders
Subpoenas or lawful legal requests
Whenever possible, we prefer to obtain your authorization before releasing information.
III. USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION
We must obtain your written authorization for:
Psychotherapy Notes
Psychotherapy notes (as defined by HIPAA) are kept separate from the clinical record and receive additional protections.
We may only use or disclose psychotherapy notes without authorization in limited circumstances, including:
Use by the provider for treatment
Training or supervision
Legal defense in actions brought by you
Required investigations by the Department of Health and Human Services
As otherwise required by law to prevent serious harm
Marketing and Sale of Information
Evergreen CMHC will not:
Use PHI for marketing purposes without your written authorization
Sell your PHI under any circumstances
IV. USES AND DISCLOSURES NOT REQUIRING AUTHORIZATION
We may use or disclose PHI without your authorization when required or permitted by law, including:
Federal, state, or local legal requirements
Reporting suspected child, elder, or dependent adult abuse or neglect
Preventing or responding to serious threats to health or safety
Health oversight activities (audits, licensing, investigations)
Judicial and administrative proceedings
Law enforcement purposes as required by law
Coroners or medical examiners
Workers’ compensation compliance
Public health activities
We may also contact you for:
Appointment reminders
Information about treatment alternatives or services
V. DISCLOSURES TO FAMILY OR OTHERS INVOLVED IN YOUR CARE
We may disclose limited PHI to individuals involved in your care or payment for care (such as family members or caregivers) when appropriate.
You have the right to object to these disclosures unless otherwise required by law or in emergency situations.
VI. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights:
1. Right to Request Restrictions
You may request limits on how we use or disclose your PHI. We are not required to agree if it impacts your care.
2. Right to Restrict Disclosure for Self-Pay Services
If you pay in full out-of-pocket, you may request that information not be shared with your health plan.
3. Right to Confidential Communications
You may request communication in a specific way (phone, email, alternate address). We will honor reasonable requests.
4. Right to Access Records
You may request copies of your record (excluding psychotherapy notes).
We will respond within 30 days. A reasonable cost-based fee may apply.
5. Right to an Accounting of Disclosures
You may request a list of certain disclosures made within the past six years (excluding treatment, payment, and operations).
6. Right to Amend Records
You may request corrections to your records. We may deny the request but will provide a written explanation.
7. Right to a Copy of This Notice
You may request a paper or electronic copy of this Notice at any time.
VII. QUESTIONS OR COMPLAINTS
If you have questions or concerns about this Notice or your privacy rights, contact:
Evergreen Clinical Mental Health Counseling LLC
Email: office@evergreencmhc.com
Phone: 419-777-5515
You may also file a complaint with:
U.S. Department of Health and Human Services
Office for Civil Rights 200 Independence Avenue, S.W. Washington, D.C. 20201
You will not be penalized for filing a complaint.
