Client Paperwork

Notice of Privacy Practices:

HIPAA Privacy Notice of Hope Redeemed Counseling Services (DBA)

 (Legal Business Name: Christa Jallorina Christian Counseling, LLC ("CJCC" in this document)) 

THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS NOTICE GIVES YOU INFORMATION REQUIRED BY THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) that prescribes legal duties and privacy practices to protect the privacy of your individual identifiable health information; this is, Protected Health Information (PHI), as that term is defined in the HIPAA under Information. 

 THE EFFECTIVE DATE OF THIS NOTICE IS November 1, 2018. Christa Jallorina Christian Counseling, LLC (CJCC) is required to follow the terms of this Notice until it is replaced. CJCC may make changes to the terms of this Notice at any time. Upon your request, we will provide you with a copy of the current Notice. CJCC reserves the right to make the changes apply to your PHI maintained in our files before and after the effective date of the new Notice. The following is a general description of how Federal and State law permits me to use and disclose your PHI. Purposes for which Christa Jallorina Christian Counseling, LLC May Use or Disclose Your Mental Health Information with your Consent Christa Jallorina Christian Counseling, LLC may request your consent for the use and/or disclosure of your PHI for treatment, payment or health care operations as described below:

 • Treatment: CJCC will use and disclose your PHI to provide, coordinate, or manage your mental health care and any related services, if you sign an Authorization to Release Information form. 

 • Payment: Your PHI will be used and disclosed, as needed, to obtain payment for your mental health care services. This may include certain activities that your health insurance plan undertakes before it approves or pays for the mental health care services I recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and utilization review activities. If more than one third-party payer is responsible for payment for your health care, CJCC may disclose your PHI to more than one health plan and those health plans may share your PHI with each other. Your PHI may also be used and disclosed as needed to obtain payment for mental health care services rendered to you by other providers. 

• Mental Health Care Operations: CJCC may use or disclose as needed your PHI in order to support delivery of mental health care services. CJCC may call you by name in the waiting area. CJCC may use or disclose your PHI, as necessary, to contact you to schedule an appointment or remind you of your appointment. Christa Jallorina Christian Counseling, LLC 571-719-7718 cjallorinalcsw@protonmail.com www.cjccounseling.com

 • Health Care Services: Your PHI may be used and disclosed to contact you and to give you PHI about treatment alternatives or other health benefits and services that may be of interest to you. 

Uses and Disclosures with Your Written Authorization 

Except as provided below, your PHI will not be used for any non-routine purposes unless you give your written authorization to do so. If you give written authorization to use or disclose your PHI for a purpose that is not described in this Notice, then, with certain exception, you may revoke it in writing at any time. Your revocation will be effective for the PHI CJCC maintains, unless CJCC has taken action in reliance on your authorization. Uses and Disclosures Without Your Consent 

• As required by law;   

 • To comply with legal proceedings, such as a court or administrative order or subpoena; 

• To law enforcement officials for limited law enforcement purposes; 

 • To a coroner, medical examiner, or funeral director about a deceased person;

• To avert a serious threat to your health or safety or the health or safety of others; 

 • To a governmental agency authorized to oversee the mental health care system or government programs; 

• To federal officials for lawful intelligence, counterintelligence, and other national security purposes; and 

 • To public mental health authorities for public health purposes. 

Your Rights 

You may make a written request to CJCC to do one or more of the following concerning your PHI: 

 • Put additional restrictions on use and disclosure of your PHI. 

 • Communicate with you in confidence about your PHI by a different means than CJCC is currently doing. 

 • See and get copies of your PHI. To do so, contact Christa at 571-719-7718 or email cjallorinalcsw@protonmail.com.  Copies will be provided via the TherapyNotes portal.**

• Receive a list of disclosures of your PHI that CJCC has made for certain purposes for six (6) years prior to your request (after November 1, 2018) with certain exceptions permitted by law, which includes exceptions for disclosure made directly to you or made pursuant to your authorization. If you want to exercise any of these rights or require further information about privacy practices, please contact us at the phone number or email above.  In certain instances, CJCC is not required to agree to your request. CJCC will give you necessary information and forms for you to complete and return to request your Information. 

**CJCC is permitted, by law, to charge you a fee for copying any documents requested in accordance with your rights as listed above. 

 Complaints

If you believe that Christa Jallorina Christian Counseling, LLC violated your privacy rights, you have the right to complain to CJCC in writing or via phone (see contact information above) or to the Secretary of the U.S. Department of Health and Human Services (USDHHS...see address & phone number below). 

An individual must file a complaint within 180 days of when he/she knew or should have known that the act or omission occurred, unless the time limit is waived by the Secretary of DHHS. Christa Jallorina Christian Counseling, LLC will not retaliate against you if you choose to file a complaint. 

USDHHS Address: 200 Independence Ave. SW, Washington D.C. 20201.   USDHHS Phone #: 1-877-696-6775