NOTICE OF PRIVACY PRACTICES

This Notice of Privacy Practices describes how Restored Life may use and disclose your Protected Health Information (“PHI”) and explains your rights regarding that information.

Restored Life is committed to protecting the privacy and confidentiality of your health information and follows applicable federal and Ohio privacy requirements.

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1. Our Responsibilities

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Restored Life is required by law to:

• Maintain the privacy and security of your PHI.

• Provide you with this Notice describing our legal duties and privacy practices.

• Follow the privacy practices described in the Notice currently in effect.

• Notify you following a breach of unsecured PHI when notification is required by law.

• Provide you with a copy of this Notice upon request.

We will not use or disclose your PHI except as described in this Notice or as otherwise permitted or required by law.

If you provide written authorization for a use or disclosure, you generally may revoke that authorization in writing at any time, except to the extent that action has already been taken in reliance upon it.

These responsibilities reflect the requirements included in HHS's current model Notice of Privacy Practices.

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2. How We May Use and Disclose Your Health Information

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HIPAA permits certain uses and disclosures of PHI without your written authorization. The following are examples of circumstances in which Restored Life may use or disclose your information.

Treatment

We may use and disclose your PHI to provide, coordinate, or manage your care.

For example, with appropriate legal authority, information may be shared with another healthcare professional involved in your treatment to coordinate care.

Payment

We may use and disclose PHI as necessary to obtain payment for services.

For example, if you use health insurance, information regarding your services may be submitted to your insurance company to obtain payment or determine coverage.

Healthcare Operations

We may use or disclose PHI for activities necessary to operate the practice and maintain the quality of services.

Examples may include administrative activities, compliance activities, professional consultation when legally and ethically appropriate, auditing, quality assessment, and other practice operations.

HIPAA specifically requires the Notice to describe treatment, payment, and healthcare-operations uses and provide examples.

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3. Uses and Disclosures Required or Permitted by Law

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There are circumstances in which Restored Life may be permitted or required to disclose PHI without your authorization.

These may include disclosures:

• Required by federal or state law.

• Related to certain public health activities.

• Related to suspected abuse, neglect, or exploitation when reporting is required or permitted by law.

• In response to certain judicial or administrative proceedings or other lawful processes.

• For certain law-enforcement purposes when legally permitted or required.

• To avert a serious threat to health or safety when disclosure is permitted or required by law.

• For health oversight activities.

• For workers' compensation or similar programs when applicable.

The exact circumstances and amount of information disclosed depend upon applicable law.

4. Uses and Disclosures Requiring Your Authorization

Uses and disclosures of your PHI that are not otherwise permitted or required by law generally require your written authorization.

When authorization is required, you may revoke that authorization in writing, except when Restored Life has already acted in reliance on it.

Restored Life will obtain authorization when required by law for uses or disclosures involving areas for which HIPAA provides additional protections.

Restored Life does not sell your PHI.

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5. Psychotherapy Notes

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Psychotherapy notes receive additional protections under HIPAA.

When Restored Life maintains information that meets HIPAA's definition of psychotherapy notes, authorization is generally required before those notes may be used or disclosed except in certain circumstances specifically permitted by law.

Psychotherapy notes are distinct from the clinical record used for treatment, billing, diagnosis, treatment planning, and other routine healthcare purposes.

YOUR RIGHTS

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6. Right to Access Your Health Information

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You have the right to inspect and obtain a copy of certain PHI maintained about you, subject to exceptions established by law.

Requests should be submitted to Restored Life. In certain circumstances, a reasonable, cost-based fee may apply as permitted by law.

Some records, including psychotherapy notes as defined by HIPAA, may be subject to different access requirements.

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7. Right to Request an Amendment

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If you believe information in your health record is incorrect or incomplete, you may request that Restored Life amend the information.

Restored Life may deny the request under circumstances permitted by law. If a request is denied, you will be provided information regarding the denial and applicable rights.

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8. Right to Request Restrictions

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You have the right to request restrictions on certain uses or disclosures of your PHI.

Restored Life is not required to agree to every requested restriction except when otherwise required by law.

For example, under certain circumstances, if you pay for a service completely out-of-pocket and request that information about that service not be disclosed to your health plan for payment or healthcare operations, Restored Life must honor the request when the requirements of HIPAA are satisfied.

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9. Right to Request Confidential Communications

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You may request that Restored Life communicate with you regarding your health information in a particular manner or at a particular location.

For example, you may request that we contact you only at a particular telephone number or email address.

Reasonable requests will be accommodated as required by law.

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10. Right to an Accounting of Disclosures

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You may request a list of certain disclosures Restored Life has made of your PHI.

This accounting does not include every disclosure. Certain disclosures, including many made for treatment, payment, healthcare operations, or pursuant to your authorization, may not be included as permitted by law.

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11. Right to a Paper or Electronic Copy of This Notice

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You have the right to receive a copy of this Notice at any time.

You may request a paper copy even if you previously agreed to receive the Notice electronically.

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12. Electronic Communications

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Restored Life may communicate with clients electronically, including through secure electronic health record systems, client portals, email, telephone, or text messaging as appropriate.

Electronic communication can involve privacy risks. Clients should avoid sending highly sensitive clinical information through unsecured email or text messages.

Where appropriate, Restored Life may encourage clients to use secure communication methods available through the practice's electronic health record system.

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13. Minors and Personal Representatives

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When services are provided to a minor or an individual who has a legally authorized personal representative, access to and disclosure of health information will be handled according to applicable federal and Ohio law.

The privacy rights of minors can vary depending upon the circumstances under which treatment is provided, consent requirements, and other applicable laws.

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14. Couples and Family Therapy

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When services involve couples or families, confidentiality and access to information may involve additional considerations.

Restored Life will explain applicable confidentiality practices, recordkeeping policies, and expectations regarding information shared during couples or family therapy as part of the informed-consent process.

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15. Business Associates

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Restored Life may use third-party service providers to perform functions involving PHI, such as electronic health records, billing, payment processing, secure communications, electronic faxing, or other administrative services.

When HIPAA requires it, Restored Life enters into appropriate Business Associate Agreements and requires those entities to appropriately safeguard PHI.

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16. Record Retention

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Restored Life maintains clinical records in accordance with applicable federal and Ohio laws and professional requirements.

Ohio's current CSWMFT Board recordkeeping rule requires records held by a licensee to be retained for seven years and kept securely with access limited to authorized persons.

COMPLAINTS

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17. If You Believe Your Privacy Rights Have Been Violated

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If you believe your privacy rights have been violated, you may submit a complaint directly to Restored Life.

Privacy Contact:
Kailynn VanHoesen, MSW, LISW-S
Restored Life
42 E. Rahn Rd., Suite 101A
Kettering, Ohio 45429

Phone: 937-902-3944
Email: kailynnvanhoesen@restored-life.org

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR).

HHS Office for Civil Rights — File a HIPAA Complaint

Restored Life will not retaliate against you for filing a privacy complaint or exercising your privacy rights.

HHS specifically requires a Notice to explain the individual's right to complain both to the provider and to HHS.

CHANGES TO THIS NOTICE

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18. Changes to Our Privacy Practices

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Restored Life reserves the right to change the terms of this Notice and its privacy practices as permitted by law.

Changes may apply to PHI already maintained by Restored Life as well as information received in the future.

When material changes are made, an updated Notice will be made available upon request and posted where required, including on the Restored Life website.

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CONTACT INFORMATION

Restored Life
Kailynn VanHoesen, MSW, LISW-S
42 E. Rahn Rd., Suite 101A
Kettering, Ohio 45429

Phone: 937-902-3944
Email: kailynnvanhoesen@restored-life.org
Website: restoredlifetherapy.org

Effective Date: September 21, 2026