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

Authentic Presence Counseling, LLC (hereafter, APC) 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.

• “Treatment, Payment and Health Care Operations”

– Treatment is when your APC 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 APC 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.

                     – Health Care Operations are activities that relate to the performance and operation of the APC 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 APC such as sharing, employing, applying, utilizing, examining, and

     analyzing information that identifies you.

• “Disclosure” applies to activities outside of APC such as releasing, transferring, or providing access to information about 

     you to other parties.

• “Consent” means that you give prior permission. You give APC consent to handle your PHI as outlined in this Notice when 

    you sign the Patient Acknowledgement form.

II. Uses and Disclosures Requiring Authorization

Your APC 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 APC 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 Association of Social Work Boards, the Board 

has the authority to subpoena confidential mental health information from me relevant to that complaint.

• 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 APC 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 APC 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 APC 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 APCs 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 

APC 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 APC upon request, even if you have 

agreed to receive the notice electronically.

Clinician’s Duties:

•  APC 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.

•  APC reserves the right to change the privacy policies and practices described in this notice. Unless APC notifies you of 

such changes, however, APC is required to abide by the terms currently in effect.

• If APC revises its policies and procedures, APC will notify you by mail, phone, fax, or e-mail.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision an APC clinician makes about access to your

records, or have other concerns about your privacy rights, you may contact Caidin Smith at 561-803-0080

If you believe that your privacy rights have been violated and wish to file a complaint with the APC office, you

may send your written complaint to Caidin Smith, 6586 Atlantic Ave # 136 Delray Beach, FL 33446. You may

also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  APC 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 05/27/2026

APC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI 

maintained by APC. APC will notify you by mail, phone, fax, or e-mail of the revision of notice and make the revised notice 

available on APC's website: https://www.authenticpresencecounselingllc.com