NOTICE OF PRIVACY PRACTICES

This Notice of Privacy Practices explains how Evergreen Psychology & Wellness, LLC protects your health information. A copy is also provided as part of your intake paperwork.

Evergreen Psychology & Wellness, LLC

1065 E Winding Creek Dr., Ste. 250

Eagle, ID 83616

(208) 423-8375

hello@evergreenpw.com

EFFECTIVE DATE: January 1, 2026

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. OUR PLEDGE REGARDING HEALTH INFORMATION

Evergreen Psychology & Wellness, LLC (“EPW”) understands that health information about you and your health care is personal. We are committed to protecting your health information (“PHI”).

We create and maintain a clinical record of the care and services you receive. This record is necessary to provide quality care and to comply with legal requirements. This Notice applies to all records of your care created or maintained by EPW.

This notice explains:

  • How EPW may use and disclose your PHI

  • Your rights regarding your PHI

  • EPW’s legal duties regarding your PHI

EPW is required by law to:

  • Maintain the privacy of your PHI

  • Provide you with this Notice of Privacy Practices

  • Abide by the terms of the Notice currently in effect.

EPW reserves the right to change the terms of this Notice. Any changes will apply to all PHI maintained by EPW. The revised Notice will be available upon request and on EPW’s website. This Notice applies to clients receiving services in all states in which EPW is legally authorized to practice, including services provided via telehealth.

II. HOW EPW MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

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

Treatment, Payment, and Health Care Operations

Federal privacy regulations allow health care providers to use or disclose PHI without written authorization for purposes of treatment, payment or health care operations. We may also disclose your PHI for:

  • Consultation with other licensed health care providers, in order to assist with diagnosis and treatment

  • Coordination of care or referrals with other health providers

  • Billing and payment activities

  • Quality assurance, supervision, or administrative operations

Disclosures for treatment purposes are not limited to the minimum necessary standard, as full access to records may be required to provide appropriate care.

Lawsuits and Disputes

If you are involved in a lawsuit, EPW may disclose your PHI in response to a court or administrative order. EPW may also respond to subpoenas or other lawful requests if reasonable efforts have been made to notify you or to obtain a protective order.

III. USES AND DISCLOSURES REQUIRING AUTHORIZATION

Psychotherapy Notes

EPW maintains psychotherapy notes as defined under 45 CFR §164.501. These notes are kept separate from your medical record. Authorization is required for most uses or disclosures of psychotherapy notes, except as permitted by law, including:

  • Use by your provider for treatment

  • Training or supervision of mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy

  • Defense in legal proceedings initiated by you.

  • Required by law for health oversight activities

  • As required by law or to prevent serious harm

Marketing and Sale of PHI. EPW will not use or disclose your PHI for marketing purposes and does not sell PHI.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION

Subject to certain limitations, EPW may disclose PHI without authorization for:

  • 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

  • Public health activities, such as reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety

  • Health oversight activities, such as audits and investigations

  • Judicial and administrative proceedings, such as responding to a court or administrative order

  • Law enforcement purposes, such as reporting crimes occurring on the premises.

  • Coroners or medical examiners

  • Research purposes, such as 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

  • Specialized government functions, such as 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.

  • Workers’ compensation compliance

  • Appointment reminders and treatment-related communications

V. USES AND DISCLOSURES WITH OPPORTUNITY TO OBJECT

  1. Disclosures to family, friends, or others. EPW may disclose PHI to family members or others involved in your care or payment unless you object. In emergencies, consent may be obtained retroactively.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI

You have the right to:

  • Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and may say “no” if we believe it would affect your health care.

  • 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.

  • Request Confidential Communications. You have the right to ask EPW 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.

  • Inspect and Obtain Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost based fee for doing so.

  • Request an Accounting of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an authorization. EPW will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost based fee for each additional request.

  • Request Corrections or Amendments. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.

  • Obtain a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

VII. COMPLAINTS

File a complaint if you feel your rights are violated. If you believe your privacy rights have been violated, you may contact EPW at:

Evergreen Psychology & Wellness, LLC

Phone: (208) 423-8375

Email: hello@evergreenpw.com

You may also file a complaint at:

U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Room 509F HHH Bldg.

Washington, D.C. 20201

EPW will not retaliate against you for filing a complaint.

California Residents: California law provides additional privacy protections for medical information. EPW complies with all applicable state and federal privacy laws, including the California Confidentiality of Medical Information Act (CMIA).