Notice Of Protected Health Information (PHI) Privacy Practices

EFFECTIVE DATE OF THIS NOTICE: This notice went into effect on April 1, 2022.


Health Insurance Portability and Accountability Act (HIPAA)

This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), which provides privacy protections and patients’ rights with regard to the use and disclosure of your Protected Health Information (PHI) when used for the purpose of treatment, payment, and health care operations.

Clients have the right to ethical treatment, and considerate, safe, and respectful care without discrimina-tion regarding race, ethnicity, skin color, gender identity, sexual orientation, sexual identification, marital status, religion, developmental or disability status, age, national origin, socioeconomic status or any oth-er protected category. Clients have the right to ask questions about any aspect of therapy, or therapeutic services. and about the therapist’s specific education, training, qualifications, licensure, and certifications. 

HIPAA requires that your therapist in private practice with Relationship Therapy, LLC. (our practice) provide you with a Notice of Privacy Practices (the Notice). The Notice explains HIPAA and its application to your PHI in greater detail.

The law requires that your therapist and/or Relationship Therapy, LLC obtain your signature acknowledging that our practice has provided you with this notice.  If you have any questions, it is your right and obligation to ask your therapist to explain the notice of privacy practices to you during your first session. Your therapist can have a further discussion prior to you signing this document.

When you sign this document, it will also represent an agreement between you, your therapist, and Relationship Therapy, LLC.  You may revoke this Agreement in writing at any time.  That revocation will be binding unless Relationship Therapy, LLC has taken action in reliance on it.



Your therapist and Relationship Therapy, LLC., understands that health information about you and your health care is personal. We are committed to protecting your personal and private health information. Your therapist and Relationship Therapy, LLC., creates a record of the care and services you receive from our practice. Our practice keeps these records to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care private practice.

This notice will inform you about the ways in which our practice may use and disclose health information about you. This notice also describes your rights regarding the health information our practice keeps about you, and describes certain obligations our practice has regarding the use and disclosure of your health information.

Relationship Therapy, LLC. Is required by law to:

  • Make sure that protected health information (“PHI”) that identifies you is kept private.
  • Give you this notice of legal duties and privacy practices with respect to health information.
  • Follow the terms of the notice that is currently in effect.
  • We can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request, and the most current version is always available online at:


    The following categories describe different ways that Relationship Therapy, LLC., uses and discloses your  health information. For each category of uses or disclosures, we will explain what it means and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways our practice is permitted to use and disclose information will fall within one of the categories.

    • For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or internal health care operations.
    • Consultations with other Healthcare Providers: Our practice may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed healthcare provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in the diagnosis and treatment of your mental health condition.
    • Referrals to other Healthcare providers: Disclosures for treatment purposes are not limited to the minimum necessary standard. 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 healthcare providers, and referrals of a patient for health care from one health care provider to another.



    1. Psychotherapy Notes. Therapists in practice with Relationship Therapy, LLC., do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your explicit signed Authorization unless the use or disclosure is:
    2. For your therapist’s use in treating you.
    3. For your 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.
    4. For your therapist or Relationship Therapy, LLC., use in defense in legal proceedings instituted by you.
    5. For use by the Secretary of Health and Human Services to investigate compliance with HIPAA.
    6. Required by law and the use or disclosure is limited to the requirements of such law.
    7. Required by law for certain health oversight activities pertaining to the originator of the psycho therapy notes.
    8. Required by a coroner who is performing duties authorized by law.
    9. Required to help avert a serious threat to the health and safety of others.
    10. Marketing Purposes: Neither your therapist nor Relationship Therapy, LLC., will not use or disclose your PHI for marketing purposes. If you elect to disclose the therapeutic relationship in an online review or professional social media comment, that is at your discretion and not authorized or requested by either your therapist or Relationship Therapy, LLC.
    11. Sale of PHI: Neither your therapist nor Relationship Therapy, LLC., will sell your PHI in the regular course of business.



    1. Disclosures to family, friends, or others: Relationship Therapy, LLC., may provide your PHI to a family member, friend, or another person that you indicate is involved in your care or the payment for your healthcare, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.


    The law protects the privacy of all communication between a patient and a therapist.  In most situations, Relationship Therapy, LLC can only release PHI about your treatment to others if you sign a written authorization form (Authorized Release of Information form) that meets certain legal requirements imposed by HIPAA.  There are some situations where Relationship Therapy, LLC is permitted or required to disclose information without either your consent or authorization. If such a situation arises, Relationship Therapy, LLC will limit disclosure to only what is legal and necessary.

    The reasons our practice may have to release your information without authorization include the following:

    • Court Order or Subpoena: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law.Relationship Therapy, LLC., cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or if your therapist receives a subpoena of which you have been properly notified and you have failed to inform either your therapist or Relationship Therapy, LLC that you oppose the subpoena.If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order either your therapist or Relationship Therapy, LLC to disclose information.
    • Government Agency: If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, either your therapist or Relationship Therapy, LLC may be required to provide it for them. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
    • Lawsuits, Disputes, and Judicial Proceedings: If a patient files a complaint or lawsuit against your therapist or Relationship Therapy, LLC, they may disclose relevant information regarding that patient in order to provide an appropriate defense. This also includes responding to a court order or administrative order.
    • Worker’s Compensation Claims: If a patient files a worker’s compensation claim, and a therapist with Relationship Therapy, LLC is providing necessary treatment related to that claim, the therapist or Relationship Therapy, LLC., must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient’s employer, the insurance carrier or an authorized qualified rehabilitation provider.
    • Business Associate Agreements: Your therapist or Relationship Therapy, LLC., may disclose the minimum necessary health information to business associates that perform functions on behalf of the company or provide Relationship Therapy, LLC. with services if the information is necessary for such functions or services. Relationship Therapy, LLC., signs agreements with all business associates known as business associate agreements or BAA’s to protect the privacy of your information and therefore business associates are not allowed to use or disclose any information other than as specified in our contract.



    • Federal & State Law: When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
    • Health Oversight: For health oversight activities, including audits and investigations.
    • Law Enforcement: For law enforcement purposes, including reporting crimes occurring on my premises.
    • Medical Examiner: To coroners or medical examiners, when such individuals are performing duties authorized by law.
    • Research: For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
    • Appointments: Appointment reminders and health-related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.


    There are some situations in which your therapist or Relationship Therapy, LLC. Is legally obligated to take action, when they believe that doing so is necessary to attempt to protect others from harm, and your therapist or Relationship Therapy, LLC. may have to reveal some information about a patient’s treatment.

    All therapists in private practice with Relationship Therapy, LLC., are mandated reporters per state law as directed by The Federal Child Abuse Prevention and Treatment Act (CAPTA).

    • Children Under 18: If your therapist or representative of Relationship Therapy, LLC., knows or has reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires that all mandated reporters, which include your therapist, files a report with the Georgia Abuse Hotline.  Once such a report is filed, your therapist may be required to provide additional information.
    • Vulnerable Adults: If your therapist or representative of Relationship Therapy, LLC., knows or has reason to suspect, that a vulnerable adult, disabled adult, or elderly person has been abused, neglected, or exploited, the law requires that the therapist or representative file a report with the Georgia Abuse Hotline.  Once such a report is filed, they may be required to provide additional information.
    • Duty to Warn: If your therapist or representative of Relationship Therapy, LLC., believes that there is a clear and immediate probability of physical harm to yourself, the client, other clients with whom you are in contact, other individuals, or to society, the therapist is required by federal law to disclose information to take protective action, including communicating the information to the potential victim per state “duty to warn” or “duty to protect” laws, appropriate family members, law enforcement authorities, or to seek hospitalization of the patient.


    Patient’s Rights:

    • Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
    • Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask your therapist or Relationship Therapy, LLC., not to share that information for the purpose of payment or our operations with your health insurer.  Your therapist or Relationship Therapy, LLC., will agree to such unless a law requires us to share that information.
    • Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, your therapist or Relationship Therapy, LLC.,  is not required to agree to a restriction you request.
    • Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full: You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
    • Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.
    • Right to Choose How You Are Sent PHI: You have the right to ask our practice to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
    • Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and a signed Authorization to Release Information form must be completed.  Furthermore, there is a copying fee charge of $.50  per page.  Please make your request well in advance and allow 30 days to receive the copies.  If your therapist or Relationship Therapy, LLC., refuses your request for access to your records, you have a right of review, which Relationship Therapy, LLC., will discuss with you upon request.
    • Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask your therapist or Relationship Therapy, LLC., to make certain changes, also known as amending, to your health information. You have to make this request in writing.  You must tell us the reasons you want to make these changes, and your therapist or Relationship Therapy, LLC., will decide if it is. If we refuse to do so, we will tell you why within 60 days.
    • Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. A PDF copy for download is available any time at the bottom of the web page at: A copy will be provided to you directly per your request at any time.
    • Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, your therapist or a representative from Relationship Therapy, LLC.,  will discuss with you the details of the accounting process.
    • Right to Choose Someone to Act for You: If someone is your legal guardian, that person can exercise your rights and make choices about your health information. Your therapist and/or Relationship Therapy, LLC., will make sure the person has this authority and can act for you before we take any action.
    • Right to Not Have Services: You have the right to decide not to receive services with Relationship Therapy, LLC. If you wish, your therapist or Relationship Therapy, LLC. will provide you with names of other qualified professionals that you may contact yourself.
    • Right to Terminate: You have the right to terminate therapeutic services with your therapist and Relationship Therapy, LLC., at any time without any legal or financial obligations other than those already accrued. Your therapist requests that you discuss your decision with them in session before terminating or at least contact them by phone to let them know you are terminating services with your therapist and Relationship Therapy, LLC.
    • Right to Release Information with Written Consent: With your written consent, any part of your record can be released to any person or agency you designate. Together, with your therapist you two will discuss whether or not  your therapist thinks from their clinical expertise that releasing the information in question to that person or agency might be harmful to you.

    VII. Therapist’s Duties

    • Therapists are required by law to maintain the privacy of PHI and to provide you the client with a notice of legal duties and privacy practices with respect to PHI.Relationship Therapy, LLC., reserves the right to change the privacy policies and practices described in this notice.  Unless Relationship Therapy, LLC., notifies you of such changes, however, we are required to abide by the terms currently in effect as stated in this notice.  If we revise our policies and procedures, your therapist will provide you with a revised notice during session. A current and updated notice of privacy practices is always available online at:



    If you are concerned that your therapist or Relationship Therapy, LLC., has violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Relationship Therapy, LLC at or (770)750-5638, the State of Georgia Department of Health, or the Secretary of the U.S. Department of Health and Human Services.


    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.


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