HIPAA NOTICE OF PRIVACY PRACTICES CONSENT

HIPAA Notice of Privacy Practices Consent

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

Last Updated: September 20, 2026

OVERVIEW

This HIPAA Notice of Privacy Practices (the “Notice”) will tell you about the ways Smith Mental Wellness and the licensed health care professionals providing professional services through such entities (“Smith Mental Wellness Providers”) (collectively the “Practice), may disclose health information about you. This Notice will also describe your rights and certain obligations that we have regarding the use and disclosure of your health information. Smith Mental Wellness is a behavioral health practice that offers services across multiple legal entities which are referred to by the HIPAA Privacy Rule as an "organized health care arrangement." Smith Mental Wellness Providers listed on this website provide health care services via in-person and telehealth. Smith Mental Wellness’s legal entities share protected health information with each other, only as necessary, to carry out treatment, payment and health care operations, and for other purposes that are permitted or required by law, as permitted by the Health Insurance Portability and Accountability Act (“HIPAA”). All of the legal entities that comprise Smith Mental Wellness agree to comply with the terms of this Notice. This Notice applies only to health information that is “protected health information” as defined by HIPAA. It does not apply to information that is not covered by HIPAA. We are required by law to: make sure that health information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to your health information; notify you following a breach of your unsecured protected health information; and follow the terms of the notice that are currently in effect. Although this notice is being provided to you electronically, and by signing an acknowledgment of receipt of this notice, you consent to the provision of this notice electronically, you have the right to request a paper copy of this notice. We reserve the right to change our privacy practices and the terms of this Notice at any time and reserve the right to make any updated or new notice provisions effective for all protected health information that we maintain. In addition, updates described in this Notice are effective for all health information maintained by Smith Mental Wellness, including any health information collected prior to the effective date hereof. You may obtain a copy of the revised notice on the website. This notice is effective as of September 20, 2026.

HOW YOUR INFORMATION IS USED

We may use and disclose your health information for the purposes of providing services and quality care. For the avoidance of doubt, providing treatment services, collecting payment and conducting healthcare operations are all necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes. Here are some helpful examples, but this list is not exhaustive:

• To provide treatment. For example, if your treating provider wants to refer you fpr another treatment modality in your insurance network, they may use your health information for the purpose of referring you.
• The Practice or its business associates may use and disclose health information in order to verify your insurance and coverage.
• To collect payment. The Practice or its business associates will submit claims for reimbursement to your insurance company in order for them to pay us for the services we provide to you, which requires using your health information.
• For healthcare operations. The Practice or its business associates will use and disclose your health information for the review of treatment procedures, and may use it to review documentation to ensure provider compliance and quality care, and may use it internally to analyze our website and technologies through which we provide you services.
• For uses and disclosures for purposes other than treatment, payment and operations, we are required to have your written authorization, unless the use or disclosure falls within an exception. Most uses and disclosures of patient notes (as that term is defined in the HIPAA Privacy Rule), uses and disclosures for marketing purposes, and disclosures that constitute the sale of Personal Information require your authorization. Additionally, federal and state law requires special privacy protections for certain health information about you ("Highly Confidential Information"), including any Records (as defined at 42 C.F.R. § 2.11) related to substance use disorder diagnosis, treatment, or referral for treatment subject to 42 C.F.R. Part 2 ("Substance Use Disorder Records") and other health information that is given special privacy protection under state or federal laws other than HIPAA. In order for us to disclose any Highly Confidential Information for a purpose other than those permitted by law, we must obtain your authorization. You may provide a single consent for all future uses or disclosures of Substance Use Disorder Records for the purposes of Treatment, Payment, and Health Care Operations as described above. Substance Use Disorder Records disclosed pursuant to a consent for Treatment, Payment, or Health Care Operations purposes may be further disclosed without your consent to the extent permitted by HIPAA.

Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we may have already taken any action in reliance on your authorization.

DISCLOSURES THAT CAN BE MADE WITHOUT AN AUTHORIZATION

• Emergencies. Sufficient information may be shared to address an immediate emergency you are facing.
• Judicial and Administrative Proceedings. We may disclose your personal health information in the course of a judicial or administrative proceeding in response to a valid court order or other legal process, including if you were to make a claim for Workers Compensation.
• Public Health Activities. If we felt you were an immediate danger to yourself or others, we may disclose health information about you to the authorities, as well as alert any other person who may be in danger.
• Child/Elder Abuse. We may disclose health information about you related to the suspicion of child and/or elder abuse or neglect.
• Criminal Activity or Danger to Others. We may disclose health information if a crime is committed on our premises or against our personnel, or if we believe there is someone who is in immediate danger.
• Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These activities might include audits or inspections and are necessary for the government to monitor the health care system and assure compliance with civil rights laws. Regulatory and accrediting organizations may review your case record to ensure compliance with their requirements. The minimum necessary information will be provided in these instances.
• Business Associates. The Practice may disclose the minimum necessary health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, the Practice contracts with a vendor for filing claims with insurance companies. In the process of filing claims, that organization will come into contact with your information. We also contract with a vendor that collects and manages internet or other electronic network activity on our sites and services and internally encodes it so that we can determine and manage information that might be health information. All of our business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract, and are obligated to promptly notify us in the event there is a breach of protected health information (as defined by HIPAA).
• Trusted Exchange Framework and Common Agreement ("TEFCA"). The Practice or its business associates may disclose health information through a TEFCA for HIPAA-authorized treatment purposes, subject to contractual agreements to protect the privacy and security of health information as required by HIPAA, in order to manage or coordinate your health care, arrange for additional services, and/or for our health care operations.
• Marketing. We may send you newsletters or information about services we provide in which we feel you might be interested. You may at any time request that your name be removed from our mailing list.
• Scheduling appointments. We may email or call you to schedule or remind you of appointments.

YOUR INDIVIDUAL RIGHTS

To exercise any of the patient rights outlined below, submit your request in writing to [email protected].

1. Right to Inspect and Copy. You have the right to look at or get copies of your health information, with limited exceptions. If you request a copy of the information, a reasonable charge may be made for the costs incurred.
2. Right to Amend. You have the right to request that we amend your health information. Your request must explain why the information should be amended. We have the right to deny your request under certain circumstances.
3. Right to an Accounting of Disclosures. You have the right to receive a list of instances in which we have disclosed your health information for a purpose other than treatment, payment, or health care operations. Such accountings remain available for six years after the last date of service at the Practice.
4. Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you, including information related to Substance Use Disorder records for which you previously gave consent. While you are in treatment, a written request should be made with your provider. To request a restriction after services are completed, you must make your written request to [email protected]. Please note that we are not required to agree to your request, except when a restriction is requested regarding a disclosure to a health plan in situations where the patient has paid for services in full and where the purpose of the disclosure is for payment. If we do agree, we will abide by the restriction unless the information is needed in an emergency or we are required to disclose it by law.
5. Right to a List of Disclosures. Upon request, you may obtain a list of disclosures by an Intermediary (as defined at 42 C.F.R. § 2.11) for the past three (3) years.
6. Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask that we contact you only by mail or at work. You must specify the alternative means or location that you would like us to use to provide you information about your health care. We will make every attempt to accommodate reasonable requests.
7. Right to File Complaints. You may complain to us and to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by contacting [email protected] or via phone at (937) 882-5540. You will not be retaliated against for filing a complaint. You may also contact the office for further information about this notice.

EMAIL AND TEXT MESSAGES

Some of our patients prefer to communicate with their provider via email or text message. Email and text messages have inherent privacy and security risks, and you should be aware of those before using emails and text messages. Errors in transmission or interception of messages can occur. Your email or text message is not a secure communication between you and your treating provider. At your health care provider’s discretion, your email or text message any and all responses may become part of your medical record. Additionally, for urgent or emergency situations, you should not rely on email communication with providers affiliated with the Practice. In those situations, you should call 911.