LEGAL FORMS

Please read these forms in their entirety and sign to acknowledge that you have read, understood, and reviewed each section, including your rights and responsibilities as well as those of your provider.

Telehealth Consent

I understand that telehealth services may be used for some or all appointments. I understand:

• Telehealth involves electronic communication.

• There may be risks related to technology failures or interruptions.

• I may withdraw consent to telehealth services at any time.

• Confidentiality protections apply to telehealth services.

HIPAA Notice of Privacy Practices Acknowledgment

This notice describes how medical infornmation about you may be used and disclosed and how you can access this infornmation. Please review it carefully.

This practice is required by law to maintain the privacy and security of your protected health information (“PHI”) in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and applicable state laws.

Protected health information includes information about your mental health, medical history, treatment, payment information, and other identifying information maintained by this practice.

How Your Information May Be Used and Disclosed

Your protected health information may be used and disclosed for the following purposes:

Treatment

Your information may be used to provide, coordinate, or manage your healthcare treatment and related services.

Payment

Your information may be used to bill and collect payment for services provided to you, including communication with insurance companies or third-party payers.

Healthcare Operations

Your information may be used for practice operations including quality assessment, supervision, licensing, compliance, and administrative activities.

Uses and Disclosures Required or Permitted by Law

Your information may be disclosed without your authorization when required or permitted by law, including but not limited to:

• Suspected abuse or neglect

• Court orders or legal proceedings

• Medical emergencies

• Threats of serious harm to yourself or others

• Public health reporting requirements

• Certain law enforcement purposes

• Compliance investigations by government agencies

Psychotherapy Notes

Psychotherapy notes receive additional protection under HIPAA. These notes are kept separate from the clinical record and generally will not be released without your written authorization except as permitted or required by law.

Your Rights Regarding Your Protected Health Information

You have the right to:

• Request access to your records

• Request a copy of your records

• Request amendments to your records

• Request restrictions on certain disclosures

• Request confidential communication methods

• Receive an accounting of certain disclosures

• Obtain a paper or electronic copy of this notice

• File a complaint without fear of retaliation

Confidential Communication Requests

You may request that this practice communicate with you in a specific manner or at a specific location (for example, only by email, phone, or mail).

Electronic Communication

Electronic communication methods such as email, text messaging, and telehealth platforms may carry some privacy risks despite reasonable safeguards. By choosing to communicate electronically, you acknowledge and accept these potential risks.

Minors

In certain circumstances, parents or legal guardians may have rights to access a minor’s treatment information as permitted by state and federal law.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with this practice or with the U.S. Department of Health and Human Services Office for Civil Rights.

Filing a complaint will not affect your access to treatment or services.

Monica Boik

Alternative Pride Wellness

464-240-1719

Monica@AlterntivePrideWellness.com

I acknowledge that I have received this copy and/or been offered a copy of the provider’s Notice of Privacy Practices, which explains how my protected health information may be used and disclosed under the Health Insurance Portability and Accountability Act (HIPAA).

Consent for Treatment

Add your text

I voluntarily consent to participate in mental health treatment/services provided by this practice. I understand that therapy outcomes cannot be guaranteed.

I understand that confidentiality may be limited in the following situations, including but not limited to:

• Suspected abuse or neglect of a child, elder, or vulnerable adult

• Serious threats of harm to self or others

• Court orders or other legal requirements

• Medical emergencies

I understand that I am responsible for payment of fees, copays, deductibles, coinsurance amounts, and any services not covered by insurance.

Notice of Privacy Practices

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. 

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

As your provider, I may use or disclose your Protected Health Information (PHI) for treatment, payment, and health care operations purposes with your consent.

• “PHI” refers to information in your health record that could identify you.

• Treatment is when I provide, coordinate, or manage your care. Example: consulting with your family physician or another therapist.

• Payment is when I use PHI to obtain reimbursement from your health insurer or to determine eligibility.

• Health Care Operations are business-related activities such as quality assessment, audits, administrative services, case management, and coordination of care.

“Use” means activities within my office. “Disclosure” means providing access to information outside my office.

II. Uses and Disclosures Requiring Authorization

I will obtain written authorization before using or disclosing your PHI for purposes outside treatment, payment, or health care operations. This includes the release of Psychotherapy Notes, which receive extra protection.

You may revoke an authorization in writing at any time, except to the extent I have already relied on it or when law allows an insurer to contest a claim.

III. Uses and Disclosures Without Consent or Authorization

I may disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse or Neglect – If I have reasonable suspicion, I must report it.

• Health Oversight – If subpoenaed or otherwise lawfully required by oversight agencies.

• Court Proceedings – If ordered by a court, or if you are being evaluated for a court-related purpose.

• Serious Threats – If you threaten serious harm to yourself or others, I may disclose information to prevent it.

• Worker’s Compensation – As required by law to comply with worker’s compensation programs.

IV. Electronic Communications (Email, Telehealth, SMS)

Email

• With your consent, we may use your email address for scheduling, billing, and other administrative purposes.

• Email is not always secure. We will avoid including detailed clinical information unless you request otherwise.

Telehealth

• We may provide services using HIPAA-compliant telehealth platforms. These services are subject to the same privacy protections as in-person visits.

SMS Texting

• What we collect: Your mobile number, your name, and limited scheduling or administrative information.

• How we use it: Appointment reminders, confirmations, office updates, and administrative communication. We do not send detailed clinical information by text.

• Who we share with: Only authorized staff at Alternative Pride Wellness. SMS consent is not shared with third parties.

• Your rights: SMS participation is optional. You may revoke consent at any time in writing or by replying “STOP.”

V. Social Media and Online Reviews

• We do not engage with patients through social media platforms (e.g., Facebook, Instagram, Google reviews).

• For your privacy, staff will not acknowledge or respond to online reviews or comments.

• Please use official channels (phone, email, patient portal) for communication.

VI. Business Associates

We may use third-party service providers (such as billing software, telehealth platforms, or texting services). These vendors are Business Associates under HIPAA and are legally required to protect your PHI under Business Associate Agreements (BAAs).

VII. Marketing and Fundraising

We do not use or disclose your PHI for marketing or fundraising purposes without your written authorization.

VIII. Data Breach Notification

In the event of a breach of unsecured PHI, we will notify you promptly, as required by HIPAA and the HITECH Act.

IX. Patient Rights

You have the right to:

• Request Restrictions on certain uses/disclosures (though we may not be required to agree).

• Confidential Communications by alternative means (e.g., billing to another address).

• Inspect and Copy your PHI in records we maintain.

• Request Amendments to your PHI if you believe it is inaccurate.

• Accounting of Disclosures of PHI.

• Paper Copy of this notice at any time.

Some requests may involve reasonable fees.

X. Provider Duties

• We are required by law to maintain the privacy of PHI and provide this notice of our legal duties.

• We reserve the right to change these policies and practices. If revised, we will provide you with an updated notice.

XI. Use and Disclosure of Substance Use Disorder Records Subject to 42 CFR Part

If applicable, your substance use disorder (“SUD”) records are protected by federal law under 42 C.F.R. Part 2 (“Part 2”). This law provides extra confidentiality protections and requires a separate patient consent for the use and disclosure of SUD counseling notes. Each disclosure made with patient consent must include a copy of the consent or a clear explanation of the scope of the consent. It must also be accompanied by a written notice containing the language in 42 CFR Part 2.32 (a). Disclosure of these records requires your explicit written consent, except in limited circumstances such as: (a) Medical Emergencies: to the extent necessary to treat you, (b) Reporting Crimes on Program Premises, (c) Child Abuse Reporting: In connection with incidents of suspected child abuse or neglect to appropriate state or local authorities, and (d) Fundraising: We will provide you with an opportunity to decline to receive any fundraising communications prior to making such communications. You may revoke this consent at any time.

Prohibitions on Use and Disclosure of Part 2 Records:

SUD records received from programs subject to Part 2, or testimony relaying the content of such records, shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless based on your written consent, or a court order after notice and an opportunity to be heard is provided to you or the holder of the record, as provided in Part 2. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested SUD record is used or disclosed.

If SUD records are disclosed to us or our business associates pursuant to your written consent for treatment, payment, and healthcare operations, we or our business associates may further use and disclose such health information without your written consent to the extent that the HIPAA regulations permit such uses and disclosures, consistent with the other provisions in this Notice regarding

PHI.

XII. Complaints

If you believe your privacy rights have been violated, you may file a complaint with us this practice or with the U.S. Department of Health and Human Services. No retaliation will occur for filing a complaint.

Monica Boik

Alternative Pride Wellness

464-240-1719

Monica@AlterntivePrideWellness.com

Consent for Use of Artificial Intelligence (AI)

As part of their ongoing commitment to provide the best possible service, and keeping with the state of the industry, We have opted to use an artificial intelligence note-taking tool that assists in generating clinical documentation based on your sessions. This allows for more time and focus to be spent on our interactions instead of taking time to jot down notes or trying to remember all the important details. A temporary recording and transcript or summary of the conversation may be created and used to generate the clinical note for that session. Your provider then reviews the content of that note to ensure its accuracy and completeness. After the note has been created, the recording and transcript are automatically deleted.

This artificial intelligence tool prioritizes the privacy and confidentiality of your personal health information. Your session information is strictly used for the purpose of your ongoing medical care. Your information is subject to strict data privacy regulations and is always secured and encrypted. Stringent business associate agreements ensure data privacy and HIPAA compliance. Any temporary data created by AI is protected by the same security as all your data has always been. Please discuss any questions or concerns you may have about this feature with your provider.

By signing this form, you consent to the use of artificial intelligence as described. You acknowledge that your participation is voluntary and not a condition of receiving services from your clinician, and that you can withdraw your consent at any time.