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Terms and Policy

Welcome to my practice. This document contains information regarding Health Insurance Portability and Accountability (HIPAA). HIPAA is a federal law aimed to protect the use and disclosure of your Protected Health Information (PHI). In this form under the section entitled “HIPAA Notice of Privacy Practices” I have included the Notice of Privacy practices that will explain more fully your rights for PHI.

I am required by law to maintain the privacy of your protected health information and to provide you with this notice, which explains my legal duties and privacy practices with respect to your protected health care information. I must abide by the terms set forth in this notice. However, I reserve the right to change the terms of this notice and make new notice provisions effective for all protected health information. After fully reading through this form and receiving answers to any questions you may have, please sign the last page to indicate that you have read and fully understood the agreement being made between us.

Serenity Foundations, PLLC has a firm commitment to the privacy of personal information provided by those using my services including my website. My policy is intended to assist you in understanding how I collect, use and safeguard the personal information you provide to me and to assist you in making informed decisions when using my services. By using the Serenity Foundations website, you consent to the practices described in this statement. By using the services on this site, you understand and agree to the following terms:

WHAT INFORMATION DO I COLLECT? When you visit my site or use my services you may provide me with personal information you knowingly choose to disclose. If you choose to use my services, you may need to give personal information and authorization to obtain information from various credit services. For example, you may need to provide the following information: - Name - Mailing address - Credit card billing address - Email address - Credit card number - Name on credit card - Credit card billing address.

EMAIL INFORMATION. If you choose to correspond with me through email, I will retain the content of your email messages together with your email address and my responses. I provide the same protections for these electronic communications that I employ in the maintenance of information received by mail, telephone, and in live sessions. There is no guarantee that others at the receiving end of the email will keep the information confidential. i.e. others at the receiving end may read your email.

SEND SERENITY FOUNDATIONS’ STAFF E-MAIL. By sending me an electronic mail message, you may be sending me personal information (e.g., name, e-mail address, etc.). I may store your name and e-mail address and other information you may send me in order to respond to your message.

HOW DO I USE THE INFORMATION THAT YOU PROVIDE TO ME? Your personal or business identifiable information will not be shared with any outside party except as may be required by law including as needed to collect payment for services, render appropriate services to the patient, and protect others who may be in harms way.

WHAT ABOUT LEGALLY COMPELLED DISCLOSURE OF INFORMATION? I may disclose information when legally compelled to do so. I may also disclose account information when I have reason to believe that disclosing this information is necessary to identify, contact or bring legal action against someone who may be violating my Terms of Service or to protect the safety of my users and the public.

VIEW OR DOWNLOAD INFORMATION. I may collect and store information for statistical purposes. For example, I may count the number of visitors to the different sections of my site to help me make them more useful to visitors. Similar information is gathered for streaming audio and video, visits to web pages that require users to log in, interactive forms or questionnaires, or for other comparable types of connections.

WEB SERVER LOG FILES. My web server log automatically collects each visitor's domain name. For visitors merely browsing my site, I only collect the domain name and user- specific browsing data regarding what pages consumers access or visit. Any information collected is used for internal review to improve the content of my web pages.

WHAT ABOUT OTHER WEBSITES LINKED TO MY WEBSITE? I am not responsible for the practices employed by Internet sites linked to or from my site or the information or content contained therein. Often links to other Internet sites are provided solely as pointers to information on topics that may be useful to the users of my site. Please remember that when you use a link to go from my website to another website, my Privacy Policy is no longer in effect. Your browsing and interaction on any other web site, including web sites which have a link on my website, is subject to that website's own rules and policies. Please read over those rules and policies before proceeding. By using my website you consent to my collection and use of your personal information as described in this Privacy Policy.

MY COMMITMENT TO DATA SECURITY. Please note that your information will be stored and processed on my computer(s). To prevent unauthorized access, maintain data accuracy, and ensure the correct use of information, I have put in place appropriate physical, electronic, and managerial procedures to safeguard and secure the information I collect online or in person.

WHAT ARE MY LIMITS OF LIABILITY? Serenity Foundations will not be liable for any direct, indirect or consequential loss or damage arising under this disclaimer or in connection with my website, whether arising in tort, contract, or otherwise – including, without limitation, any loss of profit, contracts, business, goodwill, data, income, revenue, earnings or anticipated savings, costs of time or travel, legal fees, or fees by other providers of service as engaged by Patient. Serenity Foundations PLLC's liability is limited to the patient's out-of- pocket therapy session fees purchased by patient, fulfilled by patient, and paid to Serenity Foundations, PLLC in the most recent (30) day period of time.

SERENITY FOUNDATIONS may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify the terms, here are some definitions:
• “PHI” refers to information in your health record that could identify you.
• “Treatment” is when SERENITY FOUNDATIONS provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be when SERENITY FOUNDATIONS consults with another health care provider, such as a family physician or another therapist.
• “Payment” is when SERENITY FOUNDATIONS obtains reimbursement for your healthcare. Examples of payment are when SERENITY FOUNDATIONS 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 operations of Serenity Foundations' practice. 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 Serenity Foundations' office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of Serenity Foundations’ office, such as releasing, transferring, or providing access to information about you to other parties.

Serenity Foundations may use or disclose PHI for purposes outside of treatment, payment, or 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 those instances when Serenity Foundations is asked for information for purposes outside of treatment, payment, or health care operations, I will obtain an authorization from you before releasing the information. Serenity Foundations needs to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes that the therapist may have made about my conversation during a private, group, joint, or family counseling session, which are 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 therapist has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, the law providing the insurer the right to contest the claim under the policy.


SERENITY FOUNDATIONS may use or disclose PHI without your consent or authorization in the following circumstances:
• CHILD ABUSE – Serenity Foundations is required to report PHI to the appropriate authorities when there are reasonable grounds to believe that a minor is or has been a victim of neglect or physical and/or sexual abuse.
• ADULT AND DOMESTIC ABUSE – If Serenity Foundations has responsibility for the care of an incapacitated or vulnerable adult, the therapist is required to disclose PHI when there is a reasonable basis to believe that abuse or neglect of the adult has occurred or that exploitation of the adult has occurred.
• SERIOUS THREAT TO HEALTH OR SAFETY- If you communicate to your therapist an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim(s) and the therapist believes you have the intent and ability to carry out such a threat, a duty to take reasonable precautions to prevent the harm from occurring, including disclosing information to the potential victim and the police and in order to initiate hospitalization and protection procedures. If your therapist believes there is an imminent risk that you will inflict serious harm on yourself, information may be disclosed in order to protect you.
• HEALTH OVERSIGHT ACTIVITIES- If the Arizona Board of Behavioral Health Examiners or other oversight agency is conducting an investigation, Serenity Foundations is required to disclose PHI upon receipt of a Subpoena.
• JUDICIAL AND ADMINISTRATIVE PROCEEDING- If you are involved in a court proceeding and a request is made for information about the professional services Serenity Foundations has provided you and/or records thereof, such information is privileged under state law, and Serenity Foundations will not release information without the written authorization of you or your legally appointed representative or an appropriately executed court order signed by a judge and accompanied by an appropriately executed subpoena. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
• RECORDING OF COUNSELING SESSIONS. Under no circumstances will recording of any nature be permitted in counseling sessions. Should it be determined that a recording had occurred in any portion of any session in any way, then you waive all HPO rights to your confidentiality as it pertains to your personal health information being shared with appropriate legal persons and others who may be engaged in the recovery of the recording, protection of others who may be at risk as a result of your recording including Serenity Foundations LLC, Michelle Mugge, Psy.D., LPC, or any other staff or patient who may be entangled as a result of the recording. Should it be discovered that a recording has taken place all parties engaged in that session will immediately be notified of your break of policy and confidentiality. Even if you wish to record your own private session, such recordings are prohibited.
• WHEN THE USE AND DISCLOSURE WITHOUT YOUR CONSENT OR AUTHORIZATION IS ALLOWED UNDER OTHER SECTIONS OF SECTION 164.512 OF THE PRIVACY RULE AND THE STATE’S CONFIDENTIALITY LAW. This includes certain narrowly- defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

• RIGHT TO REQUEST RESTRICTIONS: You have the right to request restrictions on certain uses and disclosures of protected health information. However, Serenity Foundations is not required to agree to a restriction 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 therapist. On your request, Serenity Foundations will send these confidential communications to another address.)
• RIGHT TO INSPECT AND COPY: You have the right to inspect or obtain a copy (or both) of your PHI in Serenity Foundations’ mental health and billing records that have been used to make decisions about you for as long as the PHI is maintained in the record. Serenity Foundations may deny your access to PHI under certain circumstances. Upon your request, your therapist will discuss with you the details of the request and denial process.
• RIGHT TO AMEND: You have the right to request an amendment of PHI as long as the PHI is maintained in the record, but such a request may be denied. Upon your request, the therapist will discuss with you the details of the amendment process. Your request for an amendment will become part of the PHI.
• RIGHT TO AN ACCOUNTING: You generally have the right to receive information regarding disclosures of PHI. On your request, your therapist will discuss with you the disclosure process.

• Your Serenity Foundations therapist is required by law to maintain privacy of PHI and to provide you with a notice of their legal duties and privacy practices with respect to PHI.
• I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
• If I revise my policies and procedures, I will notify you by mail.

If you have questions about this notice, disagree with a decision the therapist makes about access to your records, or have other concerns about your privacy rights, you may contact me in writing via registered mail to Serenity Foundations, PLLC, 2730 W. Aqua Fria Freeway, Suite 200 Office E-17, Phoenix, AZ 85027. Complaints must be in writing. You may also send a written complaint to: Office of the Secretary, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C., 20201. I will work with you as best I can under the requirements of law, my professional standards, and this policy.

The effective date of this revised notice is August 25, 2016. Serenity Foundations, PLLC reserves the right to change the terms of this notice and to make new notice provisions effective for all PHI that are maintained. However, please be assured that if the Privacy Policy changes in the future, I will not use the personal information you have submitted to me under this Privacy Policy in a manner that is materially inconsistent with this Privacy Policy, without your prior consent.
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