NOTICE OF PRIVACY PRACTICES 

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. 

 WALK BY FAITH COUNSELING, LLC (“Walk By Faith”) is required by law to maintain the privacy of your  protected health information (“PHI”) and to notify affected individuals following a breach of unsecured PHI.  “PHI” consists of all records related to your health, including demographic information, either created by  Walk By Faith or received by Walk By Faith from other health care providers. 

This Notice is prepared in accordance with the Health Insurance Portability and Accountability Act, 45 C.F.R.  164.520, and applicable Wisconsin healthcare privacy laws. We are required to provide you with notice of  our legal duties and privacy practices with respect to your PHI. These legal duties and privacy practices are  described in this Notice. Walk By Faith will abide by the terms of this Notice, or the Notice currently in effect  at the time of the use or disclosure of your PHI. 

 Walk By Faith reserves the right to change the terms of this Notice and to make any new provisions  effective for all PHI that we maintain. Patients will be provided a copy of any revised Notices upon request.  An individual may obtain a copy of the current Notice from our office at any time. 

Uses and Disclosures of Your PHI Not Requiring Your Consent 

Walk By Faith may use and disclose your PHI, without your written consent or authorization, for certain  treatment, payment, and healthcare operations. There are certain restrictions on uses and disclosures of  “treatment records,” which include registration and all other records concerning individuals who are  receiving, or who at any time have received services for mental illness, developmental disabilities,  alcoholism, or drug dependence. There are also restrictions on disclosing HIV test results. 

Treatment may include: 

• Providing, coordinating, or managing health care and related services by health care providers; • Consultations between health care providers concerning a patient; 
• Referrals to other providers for treatment. 

 For example, Walk By Faith may determine that you require the services of a specialist. In  referring you to a doctor, Walk By Faith may share or transfer your PHI to that doctor. 

Payment activities may include: 

• Activities undertaken by Walk By Faith to obtain reimbursement for services provided to you; • Determining your eligibility for benefits or health insurance coverage; 
• Managing claims and contacting your insurance company regarding payment; 
• Collection activities to obtain payment for services provided to you; 
• Reviewing health care services and discussing with your insurance company the medical  necessity of certain services or procedures, coverage under your health plan, appropriateness of  care, or justification of charges; 
• Obtaining pre-certification and pre-authorization of services to be provided to you. 

For example, Walk By Faith will submit claims to your insurance company on your behalf. This  claim identifies you, your diagnosis, and the services provided to you. 

Healthcare operations may include:

• Contacting health care providers and patients with information about treatment alternatives; • Conducting quality assessment and improvement activities; 
• Conducting outcomes evaluation and development of clinical guidelines; 
• Protocol development, case management, or care coordination; 
• Conducting or arranging for medical review, legal services, and auditing functions. 

 For example, Walk By Faith may use your diagnosis, treatment, and outcome information to  measure the quality of the services that we provide or assess the effectiveness of your treatment  when compared to patients in similar situations. 

Walk By Faith may contact you, by telephone or mail, to provide appointment reminders. You must notify  us if you do not wish to receive appointment reminders. 

We may not disclose your PHI to family members or friends who may be involved with your treatment or  care without your written permission. PHI may be released without written permission to a parent, guardian,  or legal custodian of a child; the guardian of an incompetent adult; the healthcare agent designated in an  incapacitated patient’s healthcare power of attorney; or the personal representative or spouse of a  deceased patient. 

 There are additional situations when Walk By Faith is permitted or required to use or disclose your PHI  without your consent or authorization. Examples include the following: 

As permitted or required by law:

 In certain circumstances we may be required to report PHI to legal authorities, such as law  enforcement officials, court officials, or government agencies. For example, we may have to report  abuse, neglect, domestic violence, or certain physical injuries. We are required to report gunshot  wounds or any other wound to law enforcement officials if there is reasonable cause to believe that  the wound occurred as a result of a crime. Mental health records may be disclosed to law  enforcement authorities for the purpose of reporting an apparent crime. 

For public health activities: 

We may release PHI to certain government agencies or public health authority authorized by law,  upon receipt of written request from that agency. We are required by law to report suspected child  abuse and neglect and suspected abuse of an unborn child. We may release PHI, including  treatment records, to the FDA when required by federal law. We may disclose PHI for the purpose  of reporting elder abuse or neglect, provided the subject of the abuse or neglect agrees, or if  necessary to prevent serious harm. PHI may also be released for the reporting of domestic violence  if necessary to protect the patient or community from imminent and substantial danger. 

For health oversight activities: 

We may disclose PHI, including treatment records, in response to a written request by a federal or  state governmental agency to perform legally authorized functions, such as audits, program  monitoring and evaluation, and facility or individual licensure or certification. 

Judicial and administrative proceedings: 

PHI, including treatment records, may be disclosed pursuant to a lawful court order. A subpoena  signed by a judge is sufficient to permit disclosure of all PHI except for HIV test results. 

For activities related to death: 

We may disclose PHI, except for treatment records, to a coroner or medical examiner for the purpose of completing a medical certificate or investigating a death. 

For research: 

 Under certain circumstances, and only after a special approval process, we may use and disclose  your PHI to help conduct research. 

To avoid a serious threat to health or safety: 

 PHI, including treatment records, may be disclosed where disclosure is necessary to protect the  patient or community from imminent and substantial danger. 

Uses and Disclosures of Your PHI Requiring Your Consent 

 There are additional situations when Walk By Faith requires your consent or authorization before using or  disclosing your PHI. Examples include the following: 

Psychotherapy notes: 

 We must obtain your authorization for any use or disclosure of psychotherapy notes, with several  exceptions. We may use or disclose psychotherapy notes without your authorization to carry out  the following treatment, payment or health care operations: the originator of the psychotherapy  notes may use them for treatment; we may use or disclose psychotherapy notes for our own training  programs in which students, trainees, or practitioners in mental health learn under supervision to  practice or improve their skills in group, joint, family or individual counseling; or we may use or  disclose psychotherapy notes to defend ourselves in a legal action or other proceeding brought by  you. We are required to disclose psychotherapy notes, without your authorization, when required  by the Secretary of the Department of Health and Human Services to investigate or determine our  compliance with HIPAA. We may also use or disclose psychotherapy notes to the extent that such  use or disclosure is required by law and the use or disclosure complies with and is limited to the  relevant requirements of such law. We may also, under certain circumstances, disclose  psychotherapy notes to a health oversight agency for oversight activities authorized by law with  respect to the oversight of the originator of the psychotherapy notes. We may also disclose  psychotherapy notes to a coroner or medical examiner for the purpose of identifying a deceased  person, determining a cause of death, or other duties as authorized by law. We may also use or  disclose psychotherapy notes, consistent with applicable law and standards of ethical conduct, if  we believe, in good faith, the use or disclosure is necessary to prevent or lessen a serious and  imminent threat to the health or safety of a person or the public, and if the use or disclosure is to a  person or persons reasonably able to prevent or lessen the threat, including the target of the threat. 

Marketing: 

 We must obtain your authorization for any use or disclosure of PHI for marketing, except if the  communication is in the form of a face-to-face communication made by us to you, or a promotional  gift of nominal value provided by us. 

Sale of PHI: 

We must obtain your authorization for any disclosure of PHI which is a sale of PHI. 

Walk By Faith will not make any other use or disclosure of your PHI without your written authorization. You  may revoke such authorization at any time, except to the extent that Walk By Faith has already taken  action in reliance on the authorization. Any revocation must in writing.

Your Rights Regarding Your PHI 

 You are permitted to request that restrictions be placed on certain uses or disclosures of your PHI by Walk  By Faith to carry out treatment, payment, or healthcare operations. You must request such a restriction in  writing. We are generally not required to agree to your request, though we must agree to your request to  restrict disclosure of PHI about you to a health plan if the disclosure is for the purpose of carrying out  payment or health care operations and is not otherwise required by law, and the PHI pertains solely to a  health care item or service for which you, or a person (other than the health plan) on your behalf, has paid  us in full. If we do agree to the restriction, we must adhere to the restriction, except when your PHI is  needed in an emergency treatment situation. In this event, information may be disclosed only to healthcare  providers treating you. Also, a restriction would not apply when we are required by law to disclose certain 

PHI. 

You have the right to review and/or obtain a copy of your records, with the exception of psychotherapy  notes, or information compiled for use (or in anticipation for use) in a civil, criminal, or administrative action  or proceeding. Walk By Faith may deny access under other circumstances, in which case you have the  right to have such a denial reviewed. We may charge a reasonable fee for copying your records. 

You may request that Walk By Faith send PHI, including billing information, to you by alternative means or  to alternative locations. You may also request that Walk By Faith not send information to a particular  address or location or contact you at a specific location, such as your place of employment. This request  must be submitted in writing. We will accommodate reasonable requests by you. 

You have the right to request that Walk By Faith amend portions of your healthcare records, if such  information is maintained by us. You must submit this request in writing, and under certain circumstances  the request may be denied. 

You may request to receive an accounting of the disclosures of your PHI made by Walk By Faith for the  six years prior to the date of the request. We are not required, however, to record disclosures made  pursuant to a signed consent or authorization. 

You may request and receive a paper copy of this Notice.

Any person or patient may file a complaint with Walk By Faith and/or the Secretary of Health and Human  Services if they believe their privacy rights have been violated. To file a complaint with Walk By Faith,  please contact the Privacy Officer at the following: 

Privacy Officer 

Walk By Faith Counseling, LLC 

611 North Lynndale Drive 

Appleton, Wisconsin 54914 

(920) 238-3340 

It is the policy of Walk By Faith that no retaliatory action will be made against any individual who submits  or conveys a complaint of suspected or actual non-compliance or violation of the privacy standards. 

This Notice of Privacy Practices is effective October 1, 2021.