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This Notice describes both our privacy practices for the health care components of Wellspring Family Services and our donor relations privacy practices.

Wellspring Family Services respects the privacy of our donors. Our donor information is maintained in a secured database and is used for business purposes only. Only authorized personnel have access to this information. We do not rent, sell, give away, or trade our donor information.

Wellspring Family Services is a hybrid entity under HIPAA regulations. A hybrid entity is a health care organization in which some parts of the organization engage in activities covered by HIPAA and some that do not. In a hybrid entity organization, only those parts of the organization that engage in HIPAA covered activities need to comply with HIPAA standards. At Wellspring, the Employee Assistance Program (EAP) is covered under HIPAA rules. Programs that are not covered under HIPAA regulations are Early Learning Center, Employee Stability Services, Family Store, and Housing Services. 

The Employee Assistance Program (EAP) is a confidential service that does not share or sell your personal data to third parties or affiliates.

We are required by applicable federal and state law to maintain the privacy of your health information.  We are also required to give you this Notice about our privacy practices, legal obligations, and your rights concerning your health information (“Protected Health Information” or “PHI”).  We must follow the privacy practices that are described in this Notice, which may be amended from time to time.

For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.


    A.  Permissible Uses and Disclosures without Your Written Authorization

We may use and disclose PHI without your written authorization, excluding Psychotherapy Notes as described in Section 2, for certain purposes as described below.  The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.

  1. Treatment:  We may use and disclose PHI in order to provide treatment to you.  For example, we may use PHI to diagnose and provide counseling service to you.  In addition, we may disclose PHI to other health care providers involved in your treatment to the extent they need to know the information.
  2. Payment:  We may use or disclose PHI so that services you receive are appropriately billed to, and payment is collected from, your health plan.  By way of example, we may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.
  3. Health care Operations: We may use and disclose PHI in connection with our health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities.
  4. Required or Permitted by Law: We may use or disclose PHI when we are required or permitted to do so by law.  For example, we may disclose PHI to appropriate authorities if we reasonably believe that you or someone else is a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.  In addition we may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.  Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions; in the event of a medical emergency, emergency personnel or services providers may be given necessary information; if you bring a complaint against Wellspring Family Services; in the event of the client’s death or disability, information may be released if the client’s personal representative or the beneficiary of an insurance policy on the client’s life signs a release authorizing disclosure; in the event you reveal the contemplation or commission of a crime or harmful act; for auditing purposes or  state licensing review; or as otherwise authorized by law.

B. Uses and Disclosures Requiring Your Written Authorization

We are bound by professional ethics to protect client rights to confidential communications in regards to their involvement in counseling.  For this reason, if information about your participation in therapy is to be released to anyone, we will require a signed “Release of Information” from you for any of the following:

  1. Psychotherapy Notes: Notes recorded by your therapist documenting the contents of a counseling session with you (“Psychotherapy Notes”) will be used only by your therapist and will not otherwise be used or disclosed without your written authorization unless otherwise required by law.
  2. Marketing and Fundraising Communications and Sale of PHI: We will not use your health information for marketing or fundraising purposes without your written authorization.  Furthermore, we must obtain your written authorization prior to the sale of your PHI, consistent with the related definitions and exceptions set forth in HIPAA.
  3. Other Uses and Disclosures: Uses and disclosures other than those described in Section I.A. above will only be made with your written authorization.  For example, you will need to sign an authorization form before we can send PHI to a school or to your attorney.  You may revoke any such authorization in writing at any time.


A. Right to Inspect and Copy.  You may request access to your medical record and billing records maintained by us in order to inspect and request copies of the records.  All requests for access must be made in writing.  Under limited circumstances, we may deny access to your records if we believe the information may be harmful to you or someone else.  You have the right to appeal any denials.  We may charge a fee for the costs of copying and sending you any records requested.  If you are a parent or legal guardian of a minor 13 years or older, please note that certain portions of the minor’s record that includes information pertaining to mental health, drug treatment or family planning will not be accessible to you.

   B. Right to Alternative Communications.  You may request, and we will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.

   C. Right to Request Restrictions.  You have the right to request a restriction on PHI we use or disclose for treatment, payment or health care operations.  You must request any such restriction in writing addressed to the Privacy Officer as indicated below.  We are not required to agree to any such restriction you may request except if your request is to restrict disclosing PHI to a health plan for the purpose of carrying out payment or health care operations, the disclosure is not otherwise required by law, and the PHI pertains solely to a health care item or service which has been paid in full by you or another person or entity on your behalf.

   D. Right to Accounting of Disclosures.  Upon written request, you may obtain an accounting of certain disclosures of PHI made by us in the last six years, subject to certain restrictions and limitations.

    E.  Right to Request Amendment: You have the right to request that we amend your health information.  Your request must be in writing, and it must explain why the information should be amended.  We may deny your request under certain circumstances.

    F. Right to Obtain Notice.  You have the right to obtain a paper copy of this Notice by submitting a request to our Privacy Officer at any time.

    G. Right to Receive Notification of a Breach.  We are required to notify you if we discover a breach of your unsecured PHI, according to requirements under federal law.

    H. Questions and Complaints. If you desire further information about your privacy rights, or are concerned that we have violated your privacy rights, you may email You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services.  We will not retaliate against you if you file a complaint with the Director, our Privacy Officer, or any Wellspring staff.


    A.  Effective Date.  This Notice is effective on September 23, 2013.

    B.  Changes to this Notice.  We may change the terms of this Notice at any time.  If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice.  If we change this Notice, we will post the revised notice in the waiting area of our office.  You may also obtain any revised notice by contacting the Privacy Officer.

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