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.

I. I HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI)

I am legally required by state and federal law to protect the privacy of your Protected Health Information (PHI). PHI includes individually identifiable information created or received about your past, present, or future mental health condition, health are provision, or payment for health care.

I must provide you with this Notice about my privacy practices, legal duties, and your rights concerning PHI. I am required to abide by the terms of this Notice currently in effect. I reserve the right to change the terms of this notice and my privacy policies at any time. Any changes will apply to all PHI maintained by my practice. Revised notices will be made available upon request and posted on my practice website or client portal.

II. HOW I MAY USE AND DISCLOSE YOUR PHI

1. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations (No prior authorization required)

a. For treatment: I may use or disclose your PHI to physicians, psychiatrists, psychologists, and other health care professionals who are involved in your care to coordinate or manage your treatment.

b. For Payment: I may use and disclose your PHI to bill and collect payment for services provided. This includes disclosures to credit card processing services or secure billing platforms.

c. For Health Care Operations. I may use or disclose your PHI to operate my practice, assess quality assurance, evaluate clinical care, or consult with attorneys, accountants, and practice consultants to ensure compliance with applicable laws.

2. Mandatory or Permitted Disclosures Without Your Consent

a. Required by Law: When required by federal, state, or local law, judicial proceedings, or law enforcement.

b. Mandated Abuse Reporting: Nevada law requires mental health professionals to report suspected child abuse, elder abuse, or dependent adult abuse to appropriate authorities.

c. To Avert Severe Harm and Safety Threats: To protect you, a reasonably identifiable third party, or the public from a serious and imminent threat of physical violence or harm

d. Health Oversight Activities: To the Nevada Board of Examiners for Marriage Family Therapists and Clinical Professional Counselors or other government oversight agencies during audits, license reviews, or regulatory investigations.

e. Judicial or Administrative Proceedings: Pursuant to a lawful court order, or in response to a valid subpoena under specific legal conditions.

f. Judicial and Public health Oversight: To coroners or medical examiners when mandated by law.

3. Disclosures Requiring an Opportunity to Agree or Object

a. Family, Friends, or Caregivers: I may disclose relevant PHI to a family member, relative, or close friend involved in your care or payment for care if you agree, or if I determine based on professional clinical judgment during an emergency that you do not object.

4. Reproductive Health Care Privacy Protections

a. Prohibited Disclosures: Federal law strictly prohibits the use of disclosure of your PHI to conduct a criminal, civil, or administrative investigation into, or to impose criminal, civil, or administrative liability on, any person for seeking, obtaining, providing, or facilitating lawful reproductive health care.

b. Presumption of Lawfulness: Reproductive health care is presumed lawful unless I have actual knowledge that the care provided was unlawful under the specific circumstances in which it occurred. Your PHI will not be disclosed to identify any individual for these prohibited purposes.

c. Mandatory Attestation Requirement: Before releasing your PHI for health oversight activities, judicial/ administrative proceedings, law enforcement purposes, or to coroners/ medical examiners, I am required by law to obtain a valid, signed attestation from the requester. This document confirms under penalty of law that the request is not being made for a prohibited purpose related to reproductive health care.

5. Disclosures Requiring Your Specific Written Authorization

Uses and disclosures not covered above require your explicit written authorization

a. Psychotherapy Notes: Notes kept separate from the rest of your medical record require a separate, explicit authorization for release.

b. Marketing and Sale of PHI: I will never sell your PHI or use your PHI for marketing purposes

c. Revocation: You may revoke any written authorization at any time in writing, except to the extent action has already been taken in reliance on it.

IlI. YOUR RIGHTS REGARDING YOUR PHI

1. Right to Request Restrictions: You have the right to request limits on how I use or disclose your PHI for treatment, payment, or operations. I am not required to agree to all requests, except if you pay out of pocket in full for a service and request that I not disclose PHI regarding that service to a health plan, I must honor that restriction.

2. Right to Confidential & Alternative Communications: You have the right to request that I communicate with you about your health and billing through specific channels or at alternative locations (e.g. specific emails address or phone number)

3. Right to Inspect and Copy Your Records: You have the right to inspect or receive paper or electronic copies of your clinical record. Requests must be submitted in writing. Records will be provided within 30 business days (or 15 business days for a treatment summary). Paper copies are billed at $0.60 centers per page.

4. Right to an Accounting of Disclosures: You have the right to request a list of instances where I disclosed your PHI for purposes other than treatment, payment, health care operations, or pursuant to your written authorization during the past 6 years.

5. Right to Amend Your PHI: If you feel information in your record is incorrect or incomplete, you may submit a written request to amend it, including the reason for the request. I may deny requests under certain legal criteria (e.g., if the record is accurate), but you will receive a written explanation and may submit a statement of disagreement.

6. Right to Breach Notification: You have the right to be notified in writing following any unauthorized acquisition, access, use, or disclosure (breach) of your protected health information.

7. Right to a Paper Copy of This Notice: You may request a paper copy of this notice at any time, even if you agreed to receive it electronically.

IV. HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES

If you believe your privacy rights have been violated, or you disagree with a decision regarding access to your records, you may file a complaint with me directly or with the Secretary of the U.S Department of Health and Human Services. You will not be penalized, retaliated against, or discriminated against for filing a complaint.

Practice Contact: Chris Rabanera, LMFT

8623 Mitchell Dr, Pigeon MI 48755

Phone: (702) 763-3679

Email: Chris@TheBaseEQ.com

US Department of Health and Human Services: Office for Civil Rights

Online Filing: https://www.hhs.gov/hipaa/filing-a-complaint/index.html

Mail: Office for Civil Rights 200 Independence Avenue S.W., Washington, D.C 20201

Customer Response Center: 1-800-368-1019

Nevada State Licensing Board: State of Nevada Board of Examiners for Marriage and Family Therapists and Clinical Professional Counselors

Website: https://mft.nv.gov/

Phone: (702) 486- 7388

California State Licensing Board: California Board of Behavioral Sciences

Website: https://www.bbs.ca.gov/

Michigan State Licensing Board: The Michigan Department of Licensing and Regulatory Affairs

Website: https://www.michigan.gov/lara

V. EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on 08/10/2023, and was last updated for HIPAA compliance on August 26th, 2026.