Notice of Privacy Practices
Active & Connected Family Therapy



To ensure that disclosure of Protected Health Information (“PHI”) is made consistent with applicable laws, regulations and health information standards, and to ensure that any disclosures of a patient’s PHI to a patient’s family members, other relatives, close friends or other persons designated by the patient are appropriate.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, as well as practitioner Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request, or providing one to you at your next appointment.
How do we typically use or share your health information?

We typically use or share your health information in the following ways:

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health


Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services

We may also use or disclose your PHI for treatment, payment and health care operations purposes with your consent as discussed below:
For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.
For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your consent. Examples of payment-related activities are supplying information for determination of eligibility or coverage for insurance benefits or submission of a superbill or invoice to a third party guarantor. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.
When required or allowed by law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

For Disclosure Accounting. In some instances, the HIPAA Compliance Officer will need to track information that is disclosed. All disclosures designated as trackable must be able to be provided as an account of disclosures when requested.

For Response to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Disclosure of PHI will be carried out in accordance with all applicable legal requirements and in accordance with our internal policies.

Minimum Necessary Principle

It is our policy to make a reasonable effort to use or disclose, or to request from another health care provider, the minimum amount of PHI required to achieve the particular use or disclosure unless an exception applies.

We will identify people or classes of people in its work force who need access to PHI to carry out their duties, the category or categories of PHI to which access is needed, and any conditions appropriate to such access.
For any non-routine request for disclosure of PHI that does not meet an exception, we will review the request for disclosure on an individual basis

Minimum necessary requirements do not apply to disclosures to health care providers for treatment purposes, because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.


Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization:

1. Psychotherapy Notes as defined in 45CFR§164.50. Any use or disclosure of such notes requires your authorization unless the use or disclosure is:
-For the treating therapist’s use in treating you.
-For the treating therapist’s use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

-For the treating therapist’s use in defense in legal proceedings instituted by you.
-For use by the Secretary of Health and Human Services to investigate the treating therapist’s or Practice’s compliance with HIPAA.
-Required by law and the use or disclosure is limited to the requirements of such law. -Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
-Required by a coroner who is performing duties authorized by law.
-Required to help avert a serious threat to the health and safety of others.

2. Use and disclosure of PHI for marketing purposes, including subsidized treatment communications. We will not use or disclose your PHI for marketing purposes.
3. Disclosures that constitute a sale of PHI. We will never sell your PHI.

4. Other uses and disclosures not described in this Notice of Privacy Practices.

We may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse. If we, in our professional capacity, have reasonable cause to believe that a minor child is suffering physical or emotional injury resulting from abuse inflicted upon him or her

which causes harm or substantial risk of harm to the child’s health or welfare (including sexual abuse), or from neglect, including malnutrition, we must immediately report such condition to the appropriate state agency per state law.

Elder Abuse . If we have reasonable cause to believe that an elderly person (age 60 or older) is suffering from or has died as a result of abuse, we must immediately make a report to the the appropriate state agency per state law.

Abuse of a Disabled Person. If we have reasonable cause to suspect abuse of an adult (ages 18-59) with mental or physical disabilities, we must immediately make a report to the appropriate state agency per state law.

Health Oversight. The governing licensure board (ie VA Board of Cwwwounseling, VA Board of Counseling, NC Social Work Certification and Licensure Board) has the power, when necessary, to subpoena relevant records should we be the focus of an inquiry.

Judicial or Administrative Proceedings . If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and we will not release information without written authorization from you or your legally-appointed representative, or a court order. 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.

Serious Threat to Health or Safety. If you communicate an explicit threat to kill or inflict serious bodily injury upon an identified person and you have the apparent intent and ability to carry out the threat, we must take reasonable precautions. Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization. We must also do so if we know you have a history of physical violence and believe there is a clear and present danger that you will attempt to kill or inflict bodily injury upon an identified person. Furthermore, if you present a clear and present danger to yourself and refuse to accept further appropriate treatment, and we have a reasonable basis to believe that you can be committed to a hospital, we must seek said commitment and may contact members of your family or other individuals if it would assist in protecting you.

Law Enforcement. This includes reporting crimes occurring on the premises, either during or outside of session times.

Worker’s Compensation. If you file a workers’ compensation claim, your records relevant to that claim will not be confidential to entities such as your employer, the insurer and the Division of Worker’s Compensation.
Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority. This includes coroners and medical examiners, when such individuals are performing duties authorized by the law.
Appointment reminders and health related benefits or services. We may use your PHI, including contact information, to remind you of upcoming appointments or to alert you to services that might be of benefit to you.
Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

You have the following rights regarding PHI we maintain about you:

  • ●  Right of Access to Inspect and Copy. You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your access may be denied in certain circumstances, but in some cases, you may be able to have this decision reviewed. On your request, we will discuss with you the details of the request and denial process. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.

  • ●  Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. On your request, we will provide you with details of the amendment process.

  • ●  Right to an Accounting of Disclosures. You have the right to request an accounting of PHI for which you have neither provided authorization nor consent. On request, we will discuss with you the details of the accounting process. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

  • ●  Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

  • ●  Right to Receive Confidential Communications by Alternative Means and at Alternative Locations. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. (For instance, you may not want a family member to know you are seeing us. Upon your request, we will send your bills to another address.) We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.

  • ●  Right to Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.

  • ●  Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice upon request, even if you have agreed to receive the notice electronically.

  • ●  Right to Choose Someone to Act for You . If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

  • ●  Right to File a Complaint if You Feel Your Rights are Violated . You can complain if you feel we have violated your rights by contacting our HIPAA Compliance Officer and submitting a written complaint.

    o o 434-202-4080

    You can file also a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting We will not retaliate against you for filing a complaint.

    VI. EFFECTIVE DATE OF PRIVACY PRACTICES This notice will go into effect on 1 December 2022

    Changes to the Terms of this Notice

    We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

    Acknowledgement of Receipt of Privacy Notice
    Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.