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 am required by applicable federal and state law to maintain the privacy of your health information. I am also required to give you Notice about my privacy practices, legal obligations, and your rights concerning your health information ("Protected Health Information" or "PHI"). I must follow the privacy practices that are described in this Notice (which may be amended from time to time).
For more information about my privacy practices, or for additional copies of this Notice, please contact me using the information listed in Section II G of this notice.


I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
A. Permissible Uses and Disclosures without Your Written Authorization
I may use and disclose PHI (Protected Health Information) without your written authorization, excluding Psychotherapy Notes as described in Section II, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under Federal and State law.


1. Treatment: I may use and disclose PHI in order to provide treatment to you. For example, I may use PHI to diagnose and provide counseling services to you. In addition, I may disclose PHI to other health care providers involved in our treatment or for the purpose of obtaining supervision or consultation. In the latter instance, no personal information that could be used to identify you specifically would be released (i.e. name, address, phone number, social security number etc).

2. Payment: I may use or disclose PHI so that services you receive are appropriately billed to, and payment is collected from, your health plan. By way of example, I may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.

3. Health Care Operations: I may use and disclose PHI in connection with my health care operations, including quality improvement activities required by HIPPA, accreditation, certification, licensing or credentialing activities. PHI is not required to date for licensure or credentialing processes of and individual practitioner.

4. Required or Permitted by Law: I may use or disclose PHI when I am required or permitted to do so by law. For example, I may disclose PHI to appropriate authorities if I reasonably believe that you are a possible victim of abuse or neglect. In addition I may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures may be warranted or required by law (State or Federal) such as the disclosures of PMI of a minor or an adult deemed legally incompetent to the responsible family member of legal guardian or in response to a court order or lawful process. When and where possible I will make an effort to notify you of these disclosures.


B. Uses and Disclosures Requiring Your Written Authorization

1. Psychotherapy Notes: Notes recorded by your clinician documenting the contents of a counseling session with you ("Psychotherapy Notes") will be used only by your clinician and will not otherwise be used or disclosed without your written authorization. Psychotherapy notes are protected by the privilege of patient-therapist confidentiality and will be kept in a separate secured file or shredded.
2. Marketing Communications: I will not use you health information for marketing communication without your written authorization.
3. Other Uses and Disclosures: Uses and disclosures other than those described in Section I.A. above will only be made with your written authorization. For example, you will need to sign an authorization form before I can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.

II. YOUR INDIVIDUAL RIGHTS

A. Right to Inspect and Copy. You may request access to your medical record and billing records maintained by me in order to inspect and request copies of the records. Under most circumstances, I will refuse requests for copies of psychotherapy notes to be released directly to you or any other entity. You may request a summary of treatment services provided and billing records maintained by me. All requests for treatment and billing summaries must be made in writing. Under most circumstances, I will request that we review your treatment summary together in the privacy of the clinical setting, prior to releasing it to you. I may charge a fee for the costs of preparing and sending you any requests of treatment summaries. If you are a minor, please note that certain portions of the minor's medical records may not be accessible to you in accordance with the current Sate or Federal Law.

B. Right to Alternative Communications. You may request, and I will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.

C. Right to Request Restrictions. You have the right to request a restriction on PHI used for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to the Privacy Officer as indicated below. I am not required to agree to any such restriction you may request.

D. Right to Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made. This right applies to disclosures for purposes other than treatment, payment or health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations.

E. Right to Request Amendment: You have the right to request that I amend your health information. Your request must be in writing, and it must explain why the information should be amended. I may deny your request under certain circumstances.

F. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to the Privacy Officer at any time.

G. Questions and Complaints. If you desire further information about your privacy rights, or are concerned that I have violated your privacy rights, you may contact me, the Privacy Officer, Dominique Harmon, LCSW at 108 E. Ponce de Leon Ave, Suite 215, Decatur, GA 30030, (678) 561-6994. You may also file written complaints with the Director, Office for Civil Rights of the U. S. Department of Health and Human Services, 200 Independence Avenue, S. W., Washington, D.C. 20201 (1-877-696-6775). I will not retaliate against you if you file a complaint with the Director or myself.

III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE

A. Effective Date. This Notice is effective on March 01, 2008; with amendments on October 2, 2013; with amendments or December 20, 2018.

B. Changes to this Notice. I may change the terms of this Notice at any time. If I change this Notice, I may make the new notice terms effective for all PHI that I maintain, including any information created or received prior to issuing the new notice. If I change this Notice, I will post the revised notice in the waiting area of my office. You may also obtain any revised notice by contacting the Privacy Officer.

This Form is educational only, does not constitute legal advice, and covers only Federal, not State, law.

There are a number of small housekeeping items that many individuals find helpful to have outlined prior to starting treatment.


Confidentiality. The content of therapy sessions and the identity of patients is confidential information under Georgia law. With written consent, it is possible for a patient to release specific information to others of their choosing. Confidentiality can be broken only if the therapist has reason to believe that the patient may be a danger to her/himself or others.

Mutual Consent. In my practice, I meet with clients for an initial two session intake to make an assessment of your situation and whether the treatment I provide will be helpful to you. I have found that this is an important time for clients to determine if they feel comfortable with me personally and my style of working. The choice to begin therapy will be mutually agreed upon. In the event that it is determined that we will not work together, I will make recommendations and provide referrals to other professionals that are in my professional judgment, most appropriate for your specific needs.

Availability. I can be reached at my office number (678) 561-6994. I have a confidential voice mailbox that I check multiple times a day. Monday through Friday messages should be left here. Calls received after hours or over the weekend or when I am on vacation, will be returned the day I return to the office. I am not available by a beeper or pager system. If emergencies arise after office hours, then you should report to your closest emergency room for help.

Payment for Services. My initial evaluation fee is $200 for a 60-minute intake session. My usual fees for on-going services are: $160 for a 45-50 minute individual psychotherapy session; $180 for a 50-60 minute individual psychotherapy session; unless otherwise negotiated. Full payment, by cash, check, or major credit card, is due at time of service, unless otherwise negotiated. A viable credit card is required to remain on file in your account, regardless of how you decide to make individual session payments.


I do not directly participate or bill any other health insurance companies. Most insurance companies will provide "out-of-network provider" reimbursement of some portion of your cost for mental health services. Please contact your insurance provider to learn if they provide these benefits.

I will provide you with a statement of payment at the end of each session. This statement will include all of the information you need to file a claim with your health insurance company, should you chose to do so. You are responsible for determining what your health insurance benefits are and obtaining the appropriate claim forms from your benefits office or from the insurance company. If you decide to file a claim with your health insurance provider for reimbursement, I will work with you to make sure your health insurance company has all the information they need to process the claim.

Missed Appointment Policy. You will be charged for appointments that are cancelled without 24-hour advanced notice. Insurance companies will not reimburse you for these charges. Payment for missed appointments will be due immediately, and should be mailed directly to this office.

Mailing address: Dominique Harmon, LCSW
1708 Peachtree St., NW, Suite 425

Atlanta, GA 30309-7020

You will not be scheduled for additional services if you have an outstanding balance, unless otherwise negotiated. Please do not mail cash.

If you have read and can abide by the above policies, please sign below and date.