Notice of Privacy Practices
NOTICE OF PRIVACY PRACTICES
Effective Date: June 28, 2025
Arch Theory Counseling, LLC
2184 Ben Couch Road
Blackshear GA 31516
Phone: (912) 452-0681
Email: petebush@archtheorycounseling.com
Provider: Peter Bush, LPC
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THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.Your privacy is important to us. This notice applies to all records of your care generated by Arch Theory Counseling, LLC. We are required by law to maintain the privacy of your health information and to provide you with this Notice of our legal duties and privacy practices.
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How We May Use and Disclose Health Information About You:
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1. For Treatment: We may use your health information to provide you with mental health treatment or services. For example, we may disclose information to other health care providers involved in your care
2. For Payment: We may use and disclose health information so that we can bill and receive payment from you, an insurance company, or a third party.
3. For Health Care Operations: We may use and disclose health information for practice operations. These uses and disclosures are necessary to run our practice and ensure quality care.
4. As Required by Law: We will disclose health information when required to do so by federal, state, or local law, including with the Department of Public Health and Human Services if it wants to see that we are complying with federal privacy law.
5. To Avert a Serious Threat to Health or Safety: We may use and disclose health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person,
6. For Public Health and Safety: We may disclose health information for public health activities, reporting suspected abuse or neglect, and health oversight activities (preventing or reducing a serious threat to anyone’s health or safety).
7. Legal and Administrative Proceedings: We may disclose your information in response to a court order or legal process, subject to applicable laws and regulations. We can share health information about you in response to a subpoena.
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Your Rights Regarding Health Information About You:
1. Right to Inspect and Copy: You may request access to your clinical records. We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
2. Right to Amend: If you believe information we have about you is incorrect or incomplete, you may request an amendment. We may say “no” to your request, but we will tell you why within 60 days of your request.
3. Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures we made of your information, excluding disclosures for treatment, payment, and healthcare operations.
4. Right to Request Restrictions: You may request a restriction on certain uses and disclosures. We are not required to agree, but we will comply unless there is an emergency or disclosure is required by law. If you pay for a service out-of-pocket in full, you can request that we not share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
5. Right to Request Confidential Communications: You may ask us to contact you in a specific way (e.g., at home or by mail). Or to send mail to a different address. We will say ‘yes” to all reasonable requests.
6. Right to a Paper Copy of This Notice: You may request a paper copy of this Notice at any time.
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Our Responsibilities
1.We are required by law to maintain privacy and security of your protected health information (PHI).
2.In Case of a Breach of Records: We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information
3.We must follow the duties and privacy practices described in this notice and give you a copy of it.
4.Sharing Information at Your Behest: We will not use or share your information other than described her unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
5.We Will Never Market or Sell Personal Information
6.We Will Never Share Any Substance USE Treatment Records Without Your Written Permission.
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Changes to This Notice: We reserve the right to change this notice. We will post a copy of the current notice at our office and on our website, if applicable. The notice will contain the effective date on the first page.
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Complaints:
If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.
To file a complaint with Arch Theory Counseling:
2184 Ben Couch Road
Blackshear GA 31516
Phone: (912) 452-0681
Email: petebush@archtheorycounseling.com
Provider: Peter Bush, LPC
To file with the U.S. Department of Health and Human Services:
Visit: https://www.hhs.gov/hipaa/filing-a-complaint/index.html
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Acknowledgment of Receipt:
You will be asked to sign a form acknowledging you received this Notice of Privacy Practices.