Policies and No Surprises Act

Health Insurance Portability and Accountability Act (HIPAA)


I. COMMITMENT TO CLIENT PRIVACY:   Rise Counseling is dedicated to maintaining the privacy of clients’ protected health information (PHI).  PHI is information that may identify clients and that relates to their past, present or future physical or mental health condition and related health care services either in paper or electronic format. This Notice of Privacy Practices (“Notice”) is required by law to provide clients with the legal duties and the privacy practices that RISE COUNSELING  maintains concerning client PHI.  It also describes how medical and mental health information may be used and disclosed, as well as client rights regarding client PHI.  Please read carefully and discuss any questions or concerns with client therapist.

II. LEGAL DUTY TO SAFEGUARD CLIENT PHI: By federal and state law, RISE COUNSELING  is required to ensure that client PHI is kept private.  This Notice explains when, why, and how RISE COUNSELING  would use and/or disclose client PHI. Use of PHI means when RISE COUNSELING  shares, applies, utilizes, examines, or analyzes information within its practice; PHI is disclosed when RISE COUNSELING  releases, transfers, gives, or otherwise reveals it to a third party outside of the RISE COUNSELING . With some exceptions, RISE COUNSELING  may not use or disclose more of client PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, RISE COUNSELING  is always legally required to follow the privacy practices described in this Notice.

III.  CHANGES TO THIS NOTICE:    The terms of this notice apply to all records containing client PHI that are created or retained by RISE COUNSELING   Please note that RISE COUNSELING  reserves the right to revise or amend this Notice of Privacy Practices.  Any revision or amendment will be effective for all of client records that RISE COUNSELING  has created or maintained in the past and for any of client records that RISE COUNSELING  may create or maintain in the future.  Clients may request a copy of the most current Notice at any time.

IV. HOW RISE COUNSELING  MAY USE AND DISCLOSE  PHI:  RISE COUNSELING  will not use or disclose client PHI without client written  authorization, except as described in this Notice or as described in the  “Information, Authorization and Consent to Treatment” document.  Below you will find the different categories of possible uses and disclosures with some examples.

1. For Treatment: RISE COUNSELING  may disclose client PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide client with health care services or are; otherwise involved in client care. Example: If clients are also seeing a psychiatrist for medication management, RISE COUNSELING  may disclose client PHI to her/him in order to coordinate client care.   Except for in an emergency, RISE COUNSELING  will always ask for client authorization in writing prior to any such consultation. We may also disclose client protected health information for the treatment activities of any health care provider. This too can be done without client written authorization. For example, if a clinician were to consult with another licensed health care provider about client condition, we would be permitted to use and disclose client personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of client mental health condition. Please note, all associate professional counselors on our team are under licensed supervision and consult consistently with licensed professionals.

Also note, if one’s counselor is unable to attend therapy for emergency purposes, Lorianna Kardok (lorianna@risetampacounseling.com) or Mikela Hallmark, LPC (678-744-7347) may contact them and may serve as emergency contacts they can reach out to.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

2. For Health Care Operations: RISE COUNSELING  may disclose client PHI to facilitate the efficient and correct operation of its practice, improve client care, and contact clients when necessary. Example:  We use health information about clients to manage client treatment and services.

3. To Obtain Payment for Treatment: RISE COUNSELING  may use and disclose client PHI to bill and collect payment for the treatment and services RISE COUNSELING  provided. Example: RISE COUNSELING  might send  PHI to client insurance company or managed health care plan in order to get payment for the health care services that have been provided if they are in network with provider. Rise Counseling is currently out of network with all insurance companies.   RISE COUNSELING  could also provide client PHI to billing companies, claims processing companies, and others that process health care claims for RISE COUNSELING ’s office if either client or their insurance carrier are not able to stay current with their account.  In this latter instance, RISE COUNSELING  will always do its best to reconcile this with client first prior to involving any outside agency.

4. Employees and Business Associates:  There may be instances where services are provided to RISE COUNSELING  by an employee or through contracts with third-party “business associates.”  Whenever an employee or business associate arrangement involves the use or disclosure of client PHI, RISE COUNSELING  will have a written contract that requires the employee or business associate to maintain the same high standards of safeguarding client privacy that is required of RISE COUNSELING .

Note:  This state and Federal law provides additional protection for certain types of health information, including alcohol or drug abuse, mental health and AIDS/HIV, and may limit whether and how RISE COUNSELING  may disclose information about client to others.

V. USE AND DISCLOSURE OF CLIENT PHI IN CERTAIN SPECIAL CIRCUMSTANCES – RISE COUNSELING  may use and/or disclose client PHI without client consent or authorization for the following reasons:**

1.     Law Enforcement: Subject to certain conditions, RISE COUNSELING  may disclose PHI when required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: RISE COUNSELING  may make a disclosure to the appropriate officials when a law requires RISE COUNSELING  to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.

2.     Lawsuits and Disputes:  RISE COUNSELING  may disclose information about client to respond to a court or administrative order or a search warrant.   RISE COUNSELING  may also disclose information if an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.  RISE COUNSELING  will only do this if efforts have been made to tell client about the request and  provided an opportunity to object or to obtain an appropriate court order protecting the information requested.

3.     Public Health Risks:  RISE COUNSELING  may disclose PHI to public health or legal authorities charged with preventing or controlling disease, injury, disability, to report births and deaths, and to notify persons who may have been exposed to a disease or at risk for getting or spreading a disease or condition.

4.     Food and Drug Administration (FDA):  RISE COUNSELING  may disclose to the FDA, or persons under the jurisdiction of the FDA, PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

5.     Serious Threat to Health or Safety: RISE COUNSELING  may disclose PHI if client is in such mental or emotional condition as to be dangerous to self or the person or property of others, and if RISE COUNSELING  determines in good faith that disclosure is necessary to prevent the threatened danger.  Under these circumstances, RISE COUNSELING  may provide PHI to law enforcement personnel or other persons able to prevent or mitigate such a serious threat to the health or safety of a person or the public.

6.     Minors:  If client is a minor (under 18 years of age), RISE COUNSELING  may be compelled to release certain types of information to client’s parents or guardian in accordance with applicable law.

7.     Abuse and Neglect:  RISE COUNSELING  may disclose PHI if mandated by Georgia child, elder, or dependent adult abuse and neglect reporting laws. Example: If RISE COUNSELING  has a reasonable suspicion of child abuse or neglect, RISE COUNSELING  will report this to the Georgia Department of Child and Family Services.

8.     Coroners, Medical Examiners, and Funeral Directors: RISE COUNSELING  may release PHI about client to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person, determine the cause of death or other duties as authorized by law.  RISE COUNSELING  may also disclose PHI to funeral directors, consistent with applicable law, to carry out their duties.

9.     Communications with Family, Friends, or Others:  RISE COUNSELING  may release client PHI to the person client named in client Durable Power of Attorney for Health Care (if client has one), to a friend or family member who is clients personal representative (i.e., empowered under state or other law to make health-related decisions for client), or any other person client identifies, relevant to that person’s involvement in client care or payment related to client care.  In addition, RISE COUNSELING  may disclose client PHI to an entity assisting in disaster relief efforts so that client family can be notified about client condition. Please note that in couple’s counseling, client’s therapist does not agree to keep secrets between partners. While clients have a right to individual privacy, any information shared with the therapist that may be detrimental to the other partner, the relationship as a whole, or effectiveness of therapy will not be kept secret. If one partner discloses such information to the couple’s therapist, the therapist will conclude that either that partner would like help learning how to share the information with the other partner in session, or is ready to terminate the existing relationship and receive a referral to another couple’s therapist.

10.   National  Security, Protective Services for the President, and Intelligence Activities: RISE COUNSELING  may release PHI to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, to conduct special investigations for intelligence, counterintelligence, and other national activities authorized by law.

11.   Correctional Institutions:  If client is or becomes an inmate of a correctional institution, RISE COUNSELING  may disclose PHI to the institution or its agents when necessary for client health or the health and safety of others

12.   For Research Purposes: In certain limited circumstances, RISE COUNSELING  may use information clienthave provided for medical/psychological research, but only with client written authorization.  The only circumstance where written authorization would not be required would be if the information provided could be completely disguised in such a manner that client could not be identified, directly or through any identifiers linked to client.  The research would also need to be approved by an institutional review board that has examined the research proposal and ascertained that the established protocols have been met to ensure the privacy of client information.

13.   For Workers’ Compensation Purposes:

RISE COUNSELING  may provide PHI in order to comply with Workers’ Compensation or similar programs established by law.

14.   Appointment Reminders: RISE COUNSELING  is permitted to contact client, without client prior authorization, to provide appointment reminders or information about alternative or other health-related benefits and services that client may need or that may be of interest to client.

15.   Health Oversight Activities: RISE COUNSELING  may disclose health information to a health oversight agency for activities such as audits, investigations, inspections, or licensure of facilities. These activities are necessary for the government to monitor the health care system, government programs and compliance with laws.  Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess RISE COUNSELING ’s compliance with HIPAA regulations.

16.   If Disclosure is Otherwise Specifically Required by Law.

17.   In the Following Cases, RISE COUNSELING  Will Never Share Client Information Unless Client Give us Written Permission: Marketing purposes, sale of client information, most sharing of psychotherapy notes, and fundraising.


VI. Other Uses and Disclosures Require Client Prior Written Authorization:   In any other situation not covered by this notice, RISE COUNSELING  will ask for client written authorization before using or disclosing medical information about client.  If client chose to authorize use or disclosure, client can later revoke that authorization by notifying RISE COUNSELING  in writing of client decision.  Client understands that RISE COUNSELING  is unable to take back any disclosures it has already made with client permission, RISE COUNSELING   will continue to comply with laws that require certain disclosures, and RISE COUNSELING   is required to retain records of the care that its therapists have provided to client.


1. The Right to See and Get Copies of PHI either in paper or electronic format:  In general, clients have the right to see  PHI that is in RISE COUNSELING ’s possession, or to get copies of it; however, client must request it in writing. If RISE COUNSELING  does not have the PHI, but knows who does, client will be advised how client can get it. Client will receive a response from RISE COUNSELING  within 30 days of receiving client written request. Under certain circumstances, RISE COUNSELING   may feel it must deny client request, but if it does, RISE COUNSELING  will give, in writing, the reasons for the denial.  RISE COUNSELING   will also explain client right to have its denial reviewed.  If client asks for copies of client PHI, client will be charged a reasonable fee per page and the fees associated with supplies and postage. RISE COUNSELING  may see fit to provide  a summary or explanation of the PHI, but only if client agrees to it, as well as to the cost, in advance.

2. The Right to Request Limits on Uses and Disclosures of  PHI: Clients have the right to ask that RISE COUNSELING  limit how it uses and discloses client PHI. While RISE COUNSELING  will consider the request, it is not legally bound to agree. If RISE COUNSELING  does agree to client request, it will put those limits in writing and abide by them except in emergency situations. If client pays for a service or health care item out-of-pocket in full, client can ask us not to share that information for the purpose of payment or our operations with client health insurer. Clients do not have the right to limit the uses and disclosures that RISE COUNSELING  is legally required or permitted to make.

3. The Right to Choose How RISE COUNSELING  Sends  PHI : It is client right to ask that client PHI be sent at an alternate address (for example, sending information to client work address rather than client home address) or by an alternate method (for example, via email instead of by regular mail). RISE COUNSELING  is obliged to agree to client request providing that it can give the PHI, in the format requested, without undue inconvenience.

4. The Right to Get a List of the Disclosures.  Client is entitled to a list of disclosures of client PHI that RISE COUNSELING  has made. The list will not include uses or disclosures to which client has specifically authorized (i.e., those for treatment, payment, or health care operations, sent directly to client or to client;s family; neither will the list include disclosures made for national security purposes, or to corrections or law enforcement personnel.  The request must be in writing and state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003.

RISE COUNSELING  will respond to client request for an accounting of disclosures within 60 days of receiving request. The list will include the date of the disclosure, the recipient of the disclosure (including address, if known), a description of the information disclosed, and the reason for the disclosure. RISE COUNSELING  will provide the list to client at no cost, unless client makes more than one request in the same year, in which case it will charge client a reasonable sum based on a set fee for each additional request.

5. The Right to Choose Someone to Act: If client has given someone medical power of attorney or if someone is client legal guardian, that person can exercise  rights and make choices about client health information.  We will make sure the person has this authority and can act for client before we take any action.

6. The Right to Amend PHI: If client believes that there is some error in client PHI or that important information has been omitted, it is client’s right to request that RISE COUNSELING  correct the existing information or add the missing information. Client request and the reason for the request must be made in writing. Client will receive a response within 60 days of RISE COUNSELING ’s receipt of request. RISE COUNSELING  may deny client request, in writing, if it  finds that the PHI is: (a) correct and complete, (b) forbidden to be disclosed, (c) not part of its records, or (d) written by someone other than RISE COUNSELING . Denial must be in writing and must state the reasons for the denial. It must also explain  right to file a written statement objecting to the denial. If client does not file a written objection, client still has the right to ask that client request and RISE COUNSELING ’s denial will be attached to any future disclosures of client PHI. If RISE COUNSELING  approves client request, it will make the change(s) to client PHI. Additionally, RISE COUNSELING  will tell client that the changes have been made and will advise all others who need to know about the change(s) to client PHI.

6. The Right to Get This Notice by Email: client has the right to get this notice by email. Client has the right to request a paper copy of it as well.

7. Submit all Written Requests: Submit to RISE COUNSELING ’s Director and Privacy Officer, Mikela Hallmark, MS, LPC at 4840 Roswell Rd. Building C. Suite 202 Sandy Springs, GA 30342.


VIII. COMPLAINTS:  If client is concerned  privacy rights may have been violated, or if client objects to a decision RISE COUNSELING  made about access to your PHI, you are entitled to file a complaint.  Client may also send a written complaint to the Secretary of the Department of Health and Human Services Office of Civil Rights.  RISE COUNSELING  will provide client with the address. Under no circumstances will client be penalized or retaliated against for filing a complaint.


IX. RISE COUNSELING ‘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 occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing.  If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Date of Last Revision: 4/2/21



(OMB Control Number: 0938-1401)

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.


When you see a doctor or other health care provider, you may owe certain out-of-pocket costs,     such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.



If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable  condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.


When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections  not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance  bill you unless you give written consent and give up your protections.

You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following   protections:

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
  • Your health plan generally must:
  •     Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  •     Cover emergency services by out-of-network providers.
  •     Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  •     Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact: The Georgia Secretary of State at 404-656-2881 or by emailing them here https://sos.ga.gov/cgi-bin/email.asp.

Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.