This Notice of Privacy Practices and Office Privacy Policy describes how Alliance Behavioral Health Integrated, PLLC Clinic may use, disclose, protect, store, and maintain your health information. It also explains your privacy rights and our legal duties regarding your protected health information.

Please review this notice carefully.

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Alliance Behavioral Health Integrated, PLLC Clinic is committed to protecting the privacy, confidentiality, integrity, and security of patient information. We provide behavioral health, mental health, therapy, addiction services, DUI-related services, personal injury support, limited primary care, and related healthcare services.

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For purposes of this policy, “we,” “our,” and “the Clinic” refer to Alliance Behavioral Health Integrated, PLLC Clinic. “You” and “patient” refer to the individual receiving care or the patient’s legal representative when applicable.

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1. Our Privacy Commitment

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We are required by law to maintain the privacy and security of protected health information. Protected health information may include your name, date of birth, address, contact information, medical history, diagnoses, treatment information, medications, insurance information, billing information, referral records, court or DMV-related documentation, personal injury documentation, and any other information that identifies you and relates to your healthcare.

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We will use and disclose your health information only as permitted or required by law, as authorized by you, or as described in this policy.

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We will not use or disclose your health information for reasons outside this policy unless you provide written authorization, or unless the use or disclosure is otherwise permitted or required by law.

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2. Information We May Collect or Maintain

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We may collect, receive, create, use, disclose, store, or maintain information related to:

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• Behavioral health and mental health evaluation

• Psychiatric evaluation

• Medication management

• Therapy and counseling services

• Addiction treatment and recovery support

• MAT treatment when applicable

• DUI screening and DUI education

• DMV and court compliance documentation

• Crisis prevention planning

• IOP or rehab support

• Personal injury documentation and care coordination

• Limited primary care services

• Insurance verification and billing

• Referrals from providers, courts, attorneys, agencies, employers, family members, or other authorized parties

• Patient communications, forms, signatures, electronic submissions, uploaded documents, and appointment requests

 

We follow the minimum necessary standard when required and make reasonable efforts to limit the information used, requested, or disclosed to what is reasonably necessary for the intended purpose.

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3. How We May Use and Share Your Information

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Treatment

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We may use and share your health information to provide, coordinate, or manage your care. This may include communication with providers, therapists, prescribers, referral sources, laboratories, pharmacies, hospitals, care coordinators, crisis resources, or other healthcare professionals involved in your care.

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Examples include:

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• Sharing medication information with a pharmacy

• Coordinating therapy and medication management

• Reviewing referral documents

• Communicating with another provider involved in your treatment

• Coordinating behavioral health, addiction, DUI, primary care, or personal injury-related services

 

Payment

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We may use and share your health information to bill and collect payment for services. This may include sharing information with insurance companies, Medicaid/Medicare programs if applicable, billing companies, clearinghouses, payment processors, or other entities involved in payment.

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Examples include:

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• Verifying insurance benefits

• Submitting claims

• Responding to payer requests

• Collecting patient balances

• Processing payments

 

Healthcare Operations

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We may use and share your health information for clinic operations. This may include quality improvement, staff training, credentialing, audits, compliance reviews, risk management, appointment coordination, patient communication, business planning, and internal administrative functions.

 

Examples include:

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• Reviewing patient care quality

• Training staff on documentation and privacy requirements

• Auditing records for compliance

• Improving scheduling and patient communication

• Conducting internal reviews

 

4. Behavioral Health, Mental Health, and Therapy Information

 

Behavioral health and mental health information is sensitive and is handled with heightened care. We may use or disclose mental health information for treatment, payment, and healthcare operations as permitted by law.

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In certain situations, additional restrictions may apply under federal or state law. This may include records related to psychotherapy, substance use disorder treatment, minors, court-ordered services, crisis care, domestic violence, abuse, neglect, or other specially protected information.

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We do not disclose psychotherapy notes without written authorization except in limited circumstances permitted by law. Psychotherapy notes, when maintained separately from the medical record, receive special protection.

 

5. Substance Use Disorder and Addiction Treatment Records

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Alliance Behavioral Health Integrated, PLLC Clinic provides addiction-related services. Certain substance use disorder records may be subject to additional federal confidentiality protections, including 42 CFR Part 2, when applicable.

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To the extent that 42 CFR Part 2 applies, we will not disclose substance use disorder patient records except as permitted by law, with the patient’s written consent, pursuant to a valid court order, or as otherwise authorized by applicable federal regulations.

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Substance use disorder information may have additional protections against disclosure for criminal, civil, administrative, or legislative proceedings unless the patient provides written consent or disclosure is authorized by a proper court order or other applicable legal authority.

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6. DUI, DMV, Court, and Compliance-Related Services

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If you request or are referred for DUI screening, DUI education, court compliance, DMV compliance, or related documentation, we may use and disclose information as necessary to provide the service and meet reporting requirements.

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We may disclose compliance-related information to courts, DMV entities, probation officers, attorneys, or other authorized parties only as permitted by law, authorized by you, required by court order, required by program requirements, or otherwise legally allowed.

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You should understand that court, DMV, or legally mandated services may involve documentation and reporting obligations. We will make reasonable efforts to limit disclosures to the information necessary for the required purpose.

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7. Personal Injury Documentation and Attorney-Related Requests

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If you request personal injury support, injury-related documentation, or communication with an attorney, case manager, lienholder, insurer, or third party, we may require a written authorization before releasing information.

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We may provide treatment records, appointment information, documentation, billing records, or care coordination information only as permitted by law, authorized by you, or required by legal process.

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We do not guarantee legal outcomes, case outcomes, settlement results, court results, DMV results, disability outcomes, or insurance determinations.

 

8. Limited Primary Care Information

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If you receive limited primary care services, such as annual physicals, sick visits, women’s health services, preventive care, or basic wellness visits, those records are protected under this policy and applicable law.

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Primary care information may be shared for treatment, payment, and healthcare operations, and as otherwise permitted or required by law.

 

9. Uses and Disclosures Requiring Written Authorization

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We will generally obtain your written authorization before using or disclosing your health information for:

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• Marketing purposes, except where permitted by law

• Sale of protected health information

• Disclosure of psychotherapy notes, except where permitted by law

• Release of records to an attorney, employer, school, family member, or other third party when authorization is required

• Certain substance use disorder record disclosures when additional consent is required

• Any other use or disclosure requiring authorization under applicable law

 

You may revoke your authorization in writing at any time, except to the extent we have already relied on it.

 

10. Uses and Disclosures Permitted or Required by Law

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We may use or disclose your health information without your written authorization when permitted or required by law, including but not limited to:

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• Public health activities

• Health oversight activities

• Reporting abuse, neglect, or domestic violence as required or permitted by law

• Serious threats to health or safety

• Medical emergencies

• Workers’ compensation

• Law enforcement requests when legally permitted

• Court orders, subpoenas, or other lawful legal process

• Audits, inspections, investigations, or licensure reviews

• Coroners, medical examiners, or funeral directors when applicable

• Correctional institutions or law enforcement custody situations when applicable

• Research approved under applicable legal requirements

• Compliance with federal, state, or local law

 

Where additional privacy protections apply, we will follow the stricter applicable requirement.

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11. Communication With Family, Friends, and Caregivers

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We may share limited information with a family member, friend, caregiver, or other person involved in your care or payment for care if you agree, if you do not object when given the opportunity, or if we reasonably determine that it is in your best interest and permitted by law.

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You may request that we not share information with certain individuals. We will honor reasonable requests when required by law and when we are able to do so.

 

12. Minors, Parents, Guardians, and Personal Representatives

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Parents, legal guardians, and personal representatives may have rights to access or authorize the use and disclosure of a minor’s health information, subject to federal and state law.

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In some circumstances, minors may have privacy rights regarding certain healthcare services. We will follow applicable law regarding minors, guardianship, custody, consent, and access to records.

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If there is a custody order, guardianship order, power of attorney, court order, or other legal document affecting access to records, we may request a copy before releasing information.

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13. Patient Rights

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You have the following rights regarding your protected health information, subject to legal limitations:

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• Right to Receive This Notice

  • You have the right to receive a copy of this Notice of Privacy Practices and Office Privacy Policy.

• Right to Access Your Records

  • You have the right to inspect or request a copy of your medical records, with certain exceptions. Requests must be submitted in writing. We may charge a reasonable fee when allowed by law.

• Right to Request an Amendment

  • You may request that we correct or amend your record if you believe information is incorrect or incomplete. We may deny the request in certain circumstances, but you may submit a written statement of disagreement where permitted.

• Right to Request Confidential Communications

  • You may request that we contact you in a specific way or at a specific location. We will accommodate reasonable requests when required by law.

• Right to Request Restrictions

  • You may ask us to restrict certain uses or disclosures of your health information. We are not required to agree to all requested restrictions, except in certain circumstances required by law.

• Right to Restrict Certain Disclosures to Health Plans

  • If you pay out-of-pocket in full for a service and request that we not disclose information about that service to your health plan for payment or healthcare operations, we will honor the request when required by law, unless disclosure is otherwise required by law.

• Right to an Accounting of Disclosures

  • You may request a list of certain disclosures we have made of your health information. Some disclosures, such as those for treatment, payment, and healthcare operations, may not be included unless otherwise required by law.

• Right to Choose a Personal Representative

  • You may identify a person authorized to act on your behalf. We may require documentation of that person’s authority.

• Right to File a Complaint

  • You have the right to file a complaint if you believe your privacy rights have been violated. You may file a complaint with Alliance Behavioral Health Integrated, PLLC Clinic or with the U.S. Department of Health and Human Services Office for Civil Rights.

 

We will not retaliate against you for filing a complaint.

 

14. Our Responsibilities

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Alliance Behavioral Health Integrated, PLLC Clinic is required to:

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• Maintain the privacy and security of protected health information

• Provide this notice to patients

• Follow the terms of the notice currently in effect

• Notify affected individuals when required by law if a breach occurs

• Maintain reasonable administrative, physical, and technical safeguards

• Train workforce members regarding privacy and security responsibilities

• Limit access to protected health information to authorized persons

• Maintain appropriate agreements with vendors and business associates when required

• Retain records as required by law

• Dispose of records securely when legally permitted and appropriate

 

15. Electronic Records, Online Forms, and Digital Communications

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We may collect, receive, store, maintain, and transmit information electronically, including through electronic health records, secure systems, online forms, referral forms, uploaded documents, electronic signatures, email, fax, patient portals, scheduling systems, payment systems, and authorized vendor platforms.

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Electronic communications may carry risks, including unauthorized access or misdirected communications. We use reasonable safeguards designed to protect electronic protected health information.

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By providing contact information, submitting online forms, signing electronically, or communicating with us electronically, you acknowledge that electronic communication may be used for appointment coordination, referral follow-up, administrative matters, and care-related communication, subject to applicable law and clinic policy.

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We may require additional verification before releasing sensitive information electronically.

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16. Text Messages, Email, Voicemail, and Phone Calls

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We may contact you by phone, voicemail, email, or text message for appointment reminders, scheduling, billing, referral follow-up, care coordination, or administrative purposes.

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We will make reasonable efforts to limit sensitive information in routine messages. However, standard email and text messaging may not always be encrypted. You may request alternative communication methods.

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If you do not want us to leave voicemail messages, send text messages, or use email, you must notify us in writing.

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17. Website Privacy

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Our website may collect information submitted through forms, appointment requests, referral forms, contact forms, electronic signature fields, document uploads, or analytics tools.

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Please do not submit emergency requests through the website. If you are experiencing a medical or psychiatric emergency, call 911, call or text 988, or go to the nearest emergency room.

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Website submissions may become part of the patient record or referral record when related to care, treatment coordination, billing, documentation, or healthcare operations.

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We use reasonable safeguards for website-submitted information, but no internet transmission can be guaranteed to be completely secure.

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18. Business Associates and Authorized Vendors

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We may work with vendors or service providers that help us operate the Clinic. These may include electronic health record systems, billing services, scheduling platforms, website providers, secure messaging platforms, cloud storage providers, IT support, payment processors, laboratories, transcription services, compliance consultants, or other service providers.

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When required by law, we enter into Business Associate Agreements or similar written arrangements requiring vendors to safeguard protected health information and use or disclose it only as permitted.

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19. Record Retention and Secure Disposal

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We retain patient records in accordance with applicable federal and state law, payer requirements, professional standards, and clinic policy.

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Records may be maintained in paper or electronic format. When records are eligible for destruction, we use secure disposal methods designed to protect confidentiality.

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20. Breach Notification

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If we discover a breach of unsecured protected health information, we will investigate and provide notification as required by law.

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Notification may be provided to affected individuals, the U.S. Department of Health and Human Services, and other parties when legally required.

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21. Safeguards We Use to Protect Information

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We maintain administrative, physical, and technical safeguards designed to protect protected health information.

 

Examples of safeguards may include:

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• Workforce privacy and security training

• Role-based access controls

• Password protection

• Secure record storage

• Access limitation based on job duties

• Secure disposal procedures

• Business Associate Agreements when required

• Incident response procedures

• Record retention procedures

• Device and system safeguards

• Review of privacy and security practices

• Procedures for handling subpoenas, records requests, and authorizations

• Procedures for verifying identity and authority before disclosing information

 

22. Confidentiality of Referral Forms and Uploaded Documents

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Referral forms and uploaded documents may contain protected health information. Referrers should submit only the information necessary for referral review, appointment coordination, treatment coordination, insurance verification, documentation, and related healthcare operations.

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By submitting a referral, the referring party confirms that they are authorized to submit the information and have obtained the patient’s consent or the consent of the patient’s parent, legal guardian, or authorized representative when applicable.

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23. Court Orders, Subpoenas, Attorneys, and Legal Requests

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We carefully review requests for patient information from courts, attorneys, law enforcement, insurers, employers, and other third parties.

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We may require a valid authorization, court order, subpoena, legal process, or other documentation before releasing information. We may limit disclosures to the information required or authorized by law.

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Certain behavioral health, substance use disorder, psychotherapy, minor, or specially protected records may require additional authorization or legal review before release.

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24. Emergency and Crisis Situations

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We may use or disclose information when necessary to prevent or lessen a serious and imminent threat to the health or safety of a patient or another person, when permitted or required by law.

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Alliance Behavioral Health Integrated, PLLC Clinic is not a 24/7 emergency response provider unless specifically stated in writing. For emergencies, call 911, call or text 988, or go to the nearest emergency room.

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25. Complaints and Privacy Contact

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If you believe your privacy rights have been violated, you may contact:

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Alliance Behavioral Health Integrated, PLLC Clinic
Privacy Officer / Compliance Contact: Karen Caro, Director oF Operations
Phone: 623-401-2882
Fax: 623-401-2889
Email: alliancebhiclinic@gmail.com
Address: 12801 W Bell Road, Suite 141, Surprise, AZ 85378

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

We will not retaliate against you for filing a complaint.

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26. Changes to This Policy

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We may change this policy at any time. Changes may apply to information we already have and information we receive in the future.

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When we make a material change, we will update the effective date and make the revised notice available as required by law.

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27. Acknowledgment of Receipt

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You may be asked to sign an acknowledgment confirming that you received or had the opportunity to review this Notice of Privacy Practices and Office Privacy Policy.

Signing the acknowledgment does not mean you agree to every use or disclosure. It only confirms that you received or were offered access to the notice.

Patient Name: ___________________________________________

Date of Birth: ___________________________________________

Signature: ______________________________________________

Date: __________________________________________________

Parent / Guardian / Authorized Representative, if applicable:

Relationship to Patient: ___________________________________

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