1

4Thought Counseling, LLC 4THOUGHT COUNSELING, LLC releases, categories of possible uses and disclosures with
6470 East Johns Crossing, Suite 160 transfers, gives, or otherwise reveals it to a third some examples.
Johns Creek, GA 30097 party outside of the 4THOUGHT COUNSELING 1. For Treatment: 4THOUGHT COUNSELING,
LLC. With some exceptions, 4THOUGHT LLC may disclose your PHI to physicians,
404-625-3031
COUNSELING, LLC may not use or disclose more psychiatrists, psychologists, and other licensed
of your PHI than is necessary to accomplish health care providers who provide you with
Health Insurance Portability and the purpose for which the use or disclosure is health care services or are; otherwise involved
Accountability Act (HIPAA) made; however, 4THOUGHT COUNSELING, LLC in your care. Example: If you are also seeing a
is always legally required to follow the privacy psychiatrist for medication management,
NOTICE OF PRIVACY PRACTICES practices described in this Notice. 4THOUGHT COUNSELING, LLC may disclose
your PHI to her/him in order to coordinate
III. CHANGES TO THIS NOTICE: The your care. Except for in an emergency,
I. COMMITMENT TO YOUR PRIVACY: terms of this notice apply to all records 4THOUGHT COUNSELING, LLC will always ask for
4Thought Counseling, LLC is dedicated to containing your PHI that are created or your authorization in writing prior to any such
maintaining the privacy of your protected retained by 4THOUGHT COUNSELING, LLC consultation.
health information (PHI). PHI is information Please note that 4THOUGHT COUNSELING, LLC 2. For Health Care Operations: 4THOUGHT
that may identify you and that relates to your reserves the right to revise or amend this COUNSELING, LLC may disclose your PHI to
past, present or future physical or mental Notice of Privacy Practices. Any revision or facilitate the efficient and correct operation of
health condition and related health care amendment will be effective for all of your its practice, improve your care, and contact you
services either in paper or electronic format. records that 4THOUGHT COUNSELING, LLC has when necessary. Example: We use health
This Notice of Privacy Practices (“Notice”) is created or maintained in the past and for any of information about you to manage your
required by law to provide you with the legal your records that 4THOUGHT COUNSELING, LLC treatment and services.
duties and the privacy practices that 4THOUGHT may create or maintain in the future. 3. To Obtain Payment for Treatment:
COUNSELING, LLC maintains concerning your 4THOUGHT COUNSELING, LLC will have a copy 4THOUGHT COUNSELING, LLC may use and
PHI. It also describes how medical and mental of the current Notice in the office in a visible disclose your PHI to bill and collect payment
health information may be used and disclosed, location at all times, and you may request a for the treatment and services 4THOUGHT
as well as your rights regarding your PHI. copy of the most current Notice at any time. COUNSELING, LLC provided to you. Example:
Please read carefully and discuss any questions The date of the latest revision will always be 4THOUGHT COUNSELING, LLC might send your
or concerns with your therapist. listed at the end of 4Thought Counseling, LLC PHI to your insurance company or managed
Notice of Privacy Practices. health care plan in order to get payment for the
II. LEGAL DUTY TO SAFEGUARD health care services that have been provided to
YOUR PHI: By federal and state law, IV. HOW 4THOUGHT COUNSELING, you. 4THOUGHT COUNSELING, LLC could also
4THOUGHT COUNSELING, LLC is required to LLCMAY USE AND DISCLOSE YOUR provide your PHI to billing companies, claims
ensure that your PHI is kept private. This PHI: 4THOUGHT COUNSELING, LLC will not use processing companies, and others that process
Notice explains when, why, and how or disclose your PHI without your written health care claims for 4Thought Counseling, LLC
4THOUGHT COUNSELING, LLC would use and/or authorization, except as described in this office if either you or your insurance carrier are
disclose your PHI. Use of PHI means when Notice or as described in the “Information, not able to stay current with your account. In
4THOUGHT COUNSELING, LLC shares, applies, Authorization and Consent to Treatment” this latter instance, 4THOUGHT COUNSELING,
utilizes, examines, or analyzes information document. Below you will find the different
within its practice; PHI is disclosed when

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LLC will always do its best to reconcile this with agencies, law enforcement personnel 5. Serious Threat to Health or Safety:
you first prior to involving any outside agency. and/or in an administrative proceeding. 4THOUGHT COUNSELING, LLC may disclose
4. Employees and Business Associates: There 2. Lawsuits and Disputes: 4THOUGHT your PHI if you are in such mental or
may be instances where services are provided COUNSELING, LLC may disclose information emotional condition as to be dangerous to
to 4THOUGHT COUNSELING, LLC by an about you to respond to a court or yourself or the person or property of
employee or through contracts with third-party administrative order or a search warrant. others, and if 4THOUGHT COUNSELING, LLC
“business associates.” Whenever an employee 4THOUGHT COUNSELING, LLC may also determines in good faith that disclosure is
or business associate arrangement involves the disclose information if an arbitrator or necessary to prevent the threatened
use or disclosure of your PHI, 4THOUGHT arbitration panel compels disclosure, when danger. Under these circumstances,
COUNSELING, LLC will have a written contract arbitration is lawfully requested by either 4THOUGHT COUNSELING, LLC may provide
that requires the employee or business party, pursuant to subpoena duces tectum PHI to law enforcement personnel or
associate to maintain the same high standards (e.g., a subpoena for mental health other persons able to prevent or mitigate
of safeguarding your privacy that is required of records) or any other provision authorizing such a serious threat to the health or safety
YOUR NAME. disclosure in a proceeding before an of a person or the public.
arbitrator or arbitration panel. 4THOUGHT 6. Minors: If you are a minor (under 18
Note: This state and Federal law provides COUNSELING, LLC will only do this if efforts years of age), 4THOUGHT COUNSELING, LLC
additional protection for certain types of health have been made to tell you about the may be compelled to release certain types
information, including alcohol or drug abuse, request and you have been provided an of information to your parents or guardian
mental health, and AIDS/HIV, and may limit opportunity to object or to obtain an in accordance with applicable law.
whether and how 4THOUGHT COUNSELING, LLC appropriate court order protecting the 7. Abuse and Neglect: 4THOUGHT
may disclose information about you to others. information requested. COUNSELING, LLC may disclose PHI if
3. Public Health Risks: 4THOUGHT mandated by Georgia child, elder, or
V. USE AND DISCLOSURE OF YOUR COUNSELING, LLC may disclose your PHI dependent adult abuse and neglect
PHI IN CERTAIN SPECIAL to public health or legal authorities charged reporting laws. Example: If 4THOUGHT
CIRCUMSTANCES – 4THOUGHT with preventing or controlling disease, COUNSELING, LLC has a reasonable
COUNSELING, LLC may use and/or disclose injury, disability, to report births and suspicion of child abuse or neglect,
your PHI without your consent or deaths, and to notify persons who may 4THOUGHT COUNSELING, LLC will report
authorization for the following reasons: have been exposed to a disease or at risk this to the Georgia Department of Child
1. Law Enforcement: Subject to certain for getting or spreading a disease or and Family Services.
conditions, 4THOUGHT COUNSELING, LLC condition. 8. Coroners, Medical Examiners, and
may disclose your PHI when required by 4. Food and Drug Administration (FDA): Funeral Directors: 4THOUGHT
federal, state, or local law; judicial, board, 4THOUGHT COUNSELING, LLC may disclose COUNSELING, LLC may release PHI about
or administrative proceedings; or law to the FDA, or persons under the you to a coroner or medical examiner.
enforcement. Example: 4THOUGHT jurisdiction of the FDA, PHI relative to This may be necessary, for example, to
COUNSELING, LLC may make a disclosure adverse events with respect to drugs, foods, identify a deceased person, determine the
to the appropriate officials when a law supplements, products and product cause of death or other duties as
requires 4THOUGHT COUNSELING, LLC to defects, or post marketing surveillance authorized by law. 4THOUGHT
report information to government information to enable product recalls, COUNSELING, LLC may also disclose PHI to
repairs, or replacement.

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 3

funeral directors, consistent with applicable may disclose PHI to the institution or its activities are necessary for the government
law, to carry out their duties. agents when necessary for your health or to monitor the health care system,
9. Communications with Family, Friends, or the health and safety of others government programs and compliance
Others: 4THOUGHT COUNSELING, LLC may 13. For Research Purposes: In certain limited with laws. Example: When compelled by
release your PHI to the person you named circumstances, 4THOUGHT COUNSELING, U.S. Secretary of Health and Human
in your Durable Power of Attorney for LLC may use information you have Services to investigate or assess 4Thought
Health Care (if you have one), to a friend provided for medical/psychological Counseling, LLC compliance with HIPAA
or family member who is your personal research, but only with your written regulations.
representative (i.e., empowered under state authorization. The only circumstance 17. If Disclosure is Otherwise Specifically
or other law to make health-related where written authorization would not be Required by Law.
decisions for you), or any other person you required would be if the information you 18. In the Following Cases, 4THOUGHT
identify, relevant to that person’s have provided could be completely COUNSELING, LLC Will Never Share
involvement in your care or payment disguised in such a manner that you could Your Information Unless You Give Us
related to your care. In addition, not be identified, directly or through any Written Permission: Marketing purposes,
4THOUGHT COUNSELING, LLC may disclose identifiers linked to you. The research sale of your information, most sharing of
your PHI to an entity assisting in disaster would also need to be approved by an psychotherapy notes, and fundraising. If
relief efforts so that your family can be institutional review board that has we contact you for fundraising efforts, you
notified about your condition. examined the research proposal and can tell us not to contact you again.
10. Military and Veterans: If you are a ascertained that the established protocols
member of the armed forces, 4THOUGHT have been met to ensure the privacy of VI. Other Uses and Disclosures Require Your
COUNSELING, LLC may release PHI about your information. Prior Written Authorization: In any other
you as required by military command 14. For Workers' Compensation Purposes: situation not covered by this notice, 4THOUGHT
authorities. 4THOUGHT COUNSELING, LLC 4THOUGHT COUNSELING, LLC may provide COUNSELING, LLC will ask for your written
may also release PHI about foreign PHI in order to comply with Workers' authorization before using or disclosing
military personnel to the appropriate Compensation or similar programs medical information about you. If you chose
military authority. established by law. to authorize use or disclosure, you can later
11. National Security, Protective Services for 15. Appointment Reminders: 4THOUGHT revoke that authorization by notifying
the President, and Intelligence Activities: COUNSELING, LLC is permitted to contact 4THOUGHT COUNSELING, LLC in writing of your
4THOUGHT COUNSELING, LLC may release you, without your prior authorization, to decision. You understand that 4THOUGHT
PHI about you to authorized federal provide appointment reminders or COUNSELING, LLC is unable to take back any
officials so they may provide protection to information about alternative or other disclosures it has already made with your
the President, other authorized persons, or health-related benefits and services that permission, 4THOUGHT COUNSELING, LLC will
foreign heads of state, to conduct special you may need or that may be of interest to continue to comply with laws that require
investigations for intelligence, you. certain disclosures, and 4THOUGHT
counterintelligence, and other national 16. Health Oversight Activities: 4THOUGHT COUNSELING, LLC is required to retain records
activities authorized by law. COUNSELING, LLC may disclose health of the care that its therapists have provided to
12. Correctional Institutions: If you are or information to a health oversight agency you.
become an inmate of a correctional for activities such as audits, investigations,
institution, 4THOUGHT COUNSELING, LLC inspections, or licensure of facilities. These

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VII. RIGHTS YOU HAVE REGARDING insurer. You do not have the right to limit the 30097, if known), a description of the
YOUR PHI: uses and disclosures that 4THOUGHT information disclosed, and the reason for the
1. The Right to See and Get Copies of Your COUNSELING, LLC is legally required or disclosure. 4THOUGHT COUNSELING, LLC will
PHI either in paper or electronic format: In permitted to make. provide the list to you at no cost, unless you
general, you have the right to see your PHI that 3. The Right to Choose How 4THOUGHT make more than one request in the same year,
is in 4Thought Counseling, LLCs possession, or to COUNSELING, LLCS ends Your PHI to in which case it will charge you a reasonable
get copies of it; however, you must request it in You: It is your right to ask that your PHI be sum based on a set fee for each additional
writing. If 4THOUGHT COUNSELING, LLC does sent to you at an alternate 6470 East Johns request.
not have your PHI, but knows who does, you Crossing, Suite 160. Johns Creek, GA 30097 5. The Right to Choose Someone to Act for
will be advised how you can get it. You will (for example, sending information to your You: If you have given someone medical
receive a response from 4THOUGHT work 6470 East Johns Crossing, Suite 160. power of attorney or if someone is your legal
COUNSELING, LLC within 30 days of receiving Johns Creek, GA 30097 rather than your home guardian, that person can exercise your rights
your written request. Under certain 6470 East Johns Crossing, Suite 160. Johns and make choices about your health
circumstances, 4THOUGHT COUNSELING, LLC Creek, GA 30097) or by an alternate method information. We will make sure the person
may feel it must deny your request, but if it (for example, via email instead of by regular has this authority and can act for you before we
does, 4THOUGHT COUNSELING, LLC will give mail). 4THOUGHT COUNSELING, LLC is obliged take any action.
you, in writing, the reasons for the denial. to agree to your request providing that it can 6. The Right to Amend Your PHI: If you
4THOUGHT COUNSELING, LLC will also explain give you the PHI, in the format you requested, believe that there is some error in your PHI or
your right to have its denial reviewed. If you without undue inconvenience. that important information has been omitted, it
ask for copies of your PHI, you will be charged 4. The Right to Get a List of the Disclosures. is your right to request that 4THOUGHT
a reasonable fee per page and the fees You are entitled to a list of disclosures of your COUNSELING, LLC correct the existing
associated with supplies and postage. PHI that 4THOUGHT COUNSELING, LLC has information or add the missing information.
4THOUGHT COUNSELING, LLC may see fit to made. The list will not include uses or Your request and the reason for the request
provide you with a summary or explanation of disclosures to which you have specifically must be made in writing. You will receive a
the PHI, but only if you agree to it, as well as to authorized (i.e., those for treatment, payment, response within 60 days of 4Thought Counseling,
the cost, in advance. or health care operations, sent directly to you, LLC receipt of your request. 4THOUGHT
2. The Right to Request Limits on Uses and or to your family; neither will the list include COUNSELING, LLC may deny your request, in
Disclosures of Your PHI: You have the right to disclosures made for national security writing, if it finds that the PHI is: (a) correct
ask that 4THOUGHT COUNSELING, LLC limit how purposes, or to corrections or law enforcement and complete, (b) forbidden to be disclosed, (c)
it uses and discloses your PHI. While personnel. The request must be in writing and not part of its records, or (d) written by
4THOUGHT COUNSELING, LLC will consider your state the time period desired for the someone other than YOUR NAME. Denial must
request, it is not legally bound to agree. If accounting, which must be less than a 6-year be in writing and must state the reasons for the
4THOUGHT COUNSELING, LLC does agree to period and starting after April 14, 2003. denial. It must also explain your right to file a
your request, it will put those limits in writing 4THOUGHT COUNSELING, LLC will respond written statement objecting to the denial. If you
and abide by them except in emergency to your request for an accounting of disclosures do not file a written objection, you still have the
situations. If you pay for a service or health within 60 days of receiving your request. The right to ask that your request and 4Thought
care item out-of-pocket in full, you can ask us list will include the date of the disclosure, the Counseling, LLC denial will be attached to any
not to share that information for the purpose of recipient of the disclosure (including 6470 East future disclosures of your PHI. If 4THOUGHT
payment or our operations with your health Johns Crossing, Suite 160. Johns Creek, GA COUNSELING, LLC approves your request, it will

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 5

make the change(s) to your PHI. Additionally, occurs that may have compromised the privacy
4THOUGHT COUNSELING, LLC will tell you that or security of your information. We must
the changes have been made and will advise all follow the duties and privacy practices
others who need to know about the change(s) described in this notice and give you a copy of
to your PHI. it. We will not use or share your information
6. The Right to Get This Notice by Email: You other than as described here unless you tell us
have the right to get this notice by email. You we can in writing. If you tell us we can, you
have the right to request a paper copy of it as may change your mind at any time. Let us
well. know in writing if you change your mind.
7. Submit all Written Requests: Submit to
4Thought Counseling, LLC’s Director and Privacy Date of Last Revision: 12/30/2021
Officer, Jessica S Fouts, at the 6470 East Johns
Crossing, Suite 160. Johns Creek, GA 30097
listed on top of page one of this document.

VIII. COMPLAINTS: If you are concerned

your privacy rights may have been violated, or
if you object to a decision 4THOUGHT
COUNSELING, LLC made about access to your
PHI, you are entitled to file a complaint. You
may also send a written complaint to the
Secretary of the Department of Health and
Human Services Office of Civil Rights.
4THOUGHT COUNSELING, LLC will provide you
with the 6470 East Johns Crossing, Suite
160.Johns Creek, GA 30097. Under no
circumstances will you be penalized or
retaliated against for filing a complaint.
Please discuss any questions or concerns with
your therapist. Your signature on the
“Information, Authorization, and Consent to
Treatment” (provided to you separately)
indicates that you have read and understood
this document.

IX. 4Thought Counseling, LLC’s

Responsibilities: We are required by law to
maintain the privacy and security of your PHI.
We will let you know promptly if a breach

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