Notice of Privacy Practices

 ZALFI  (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain. (*The Practice does NOT provide Emergency services and if there is an Emergency please call 911).
 

YOUR RIGHTS

Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.
 

To inspect and copy PHI.
• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.

• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.
 

To amend PHI.
• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.
 

To request confidential communications.
• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.
 

To limit what is used or shared.
• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.
 

To receive a copy of this Notice.
• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.
 

To choose someone to act for you.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.
 

OUR USES AND DISCLOSURES

1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:
 

To treat you.
• The Practice can use and share PHI with other professionals who are treating you. (e.g., your primary care doctor asks about your mental health treatment)
 

To run the health care operations.
• The Practice can use and share PHI to run the business, improve your care, and contact you. (e.g., send you appointment reminders if you choose)
 

To bill for your services.
• The Practice can use and share PHI to bill and get payment from health plans or other entities. (e.g., give PHI to your health insurance plan to pay for your services)
 

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:
 

To help with public health and safety issues
• Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
• Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
• Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
• Serious threat to health or safety: To prevent a serious and imminent threat.
• Abuse or Neglect: To report abuse, neglect, or domestic violence.
 

To comply with law, law enforcement, or other government requests
• Required by law: If required by federal, state or local law.
• Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request.
• Law enforcement: For law locate and identify you or disclose information about a victim of a crime.
• Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.
• National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
• Workers' Compensation: To comply with workers' compensation laws or support claims.
 

To comply with other requests
• Coroners and Funeral Directors: To perform their legally authorized duties.
• Organ Donation: For organ donation or transplantation.
• Research: For research that has been approved by an institutional review board.
• Inmates: The Practice created or received your PHI in the course of providing care.
• Business Associates: To organizations that perform functions, activities or services on our behalf.
 

3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object
Unless you object, the Practice may disclose PHI:

To your family, friends, or others if PHI directly relates to that person's involvement in your care.
 

4. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes: Marketing, sale of PHI, and psychotherapy notes.
 

You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.
 

OUR RESPONSIBILITIES

• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice is required to abide by the terms of this Notice currently in effect.
• The Practice reserves the right to amend this Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website www.ZALFI.org  
• The Practice will inform you if PHI is compromised in a breach.
 

This Notice is effective on January 1, 2023. 

This form is called a Consent for Services and Practice Policies (the "Consent"). Your therapist, counselor, psychologist, doctor, nurse practitioner, or other health professional ("Provider") at Zalfi LLC (the "Facility"/"Practice") has asked you to read and sign this Consent before you start mental health treatment. Please review the information. If you have any questions, contact your Provider.
 

THE TREATMENT PROCESS
Treatment is a collaborative process where you and your Provider will work together to achieve goals that you define. Therapy and/or medication management (“Treatment”) generally show positive outcomes for individuals who follow the process. Treatment can further include labs, other diagnostic testing, education, procedures considered advisable, and services rendered by other healthcare professionals. Some clients may be required to be seen in person at least once prior to telehealth services. Some services at the Facility may be rendered to clients by Providers who are independent contractors. Better outcomes are often associated with a good therapeutic relationship between a client and their Provider. 

TREATMENT OUTCOMES

You acknowledge that no guarantee has been made to you and/or the patient regarding the outcome of any services provided. This includes all therapy, treatment, tests, procedures, and visits while at the Facility. You, the client, understand that our providers exercise their judgment when rendering services and are not employees of the Facility but independent contractors. 

TELEHEALTH SERVICES
To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. You have the right to withdraw your consent for telehealth at any time. Your provider may also require you to be seen in-person and terminate your telehealth sessions at any time. There are some risks and benefits to using telehealth (*Telehealth is NOT an Emergency service and if there is an Emergency you should call 911):
 

Risks
• Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
• Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
• Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.
 

Benefits
• Flexibility. You can attend therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
 

Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.
• Do not use video or audio to record your session.
• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.

Other
• Facility staff may be present during the telehealth visit to help with equipment. Your healthcare provider will omit any sensitive details about your care and ask staff to leave as soon as possible. 

• Through telehealth you may be prescribed medications. According to certain federal and/or state laws you may be required to be seen in-person to receive some medications. 

CONFIDENTIALITY
Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
• Your Provider may speak to other healthcare providers involved in your care.
• Your Provider may speak to emergency personnel.
• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first and will only share the minimum information needed while making a report.
• If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement.
• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.
 

RECORD KEEPING
Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record (“EHR”). The EHR has several safety features to protect your personal information.
 

COMMUNICATION
You decide how to communicate with your Provider outside of your sessions. You have several options:
 

Texting/Email
• Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
 

Secure Communication
• Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you.
 

Social Media/Review Websites
• If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
• Your provider and the Facility may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back.
• If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.
 

FEES AND PAYMENT FOR SERVICES
 

You may be required to pay for services and other fees. You will be provided with these costs prior to beginning therapy and should confirm with your insurance if part or all of these fees may be covered. You should also know about the following:
• No-Show and Late Cancellation
• If you are unable to attend therapy/Provider visits, you must contact your Provider a minimum of 24 hours before your session. Otherwise, you may subject to fees outlined in your fee agreement. Insurance does not cover these fees.

• If you are a cash/self pay client, you may request a Good Faith Estimate.

Fee Agreement 

Medication Management/Psychiatric Care

• Request Good Faith Estimate for Cash/Self Pay. 

Intensive Outpatient Program (IOP)

• Chemical Dependency IOP per day - $350 
• Psychiatric IOP per day - $350

Partial Hospitalization Program (PHP)

• PHP per day - $500

PHI Fees (Copies of Medical Records)

• Labor Fee $20 (includes first 10 pages), pages 11-50 $0.50/page, pages 51 and greater $0.25/page, Cost of postage can vary, Expedite Fee of $10 if needed in 2 days, Certifying Fee $20

Administrative Fees

• Preparing Documents - $15/30 minutes
• Court Appearance - $800/hr

ESA (Emotional Support Animal) Letters

• Preparing Documents - $180

Cancellation Policy

• Contact facility 24 hours in advance to cancel your appointment to avoid incurring a $45 no call/no show fee. Same fee applies to No Call No Show. You will be charged $45 for your 1st missed appointment, $45 for 2nd missed appointment, $45 for third missed appointment, and may be dismissed from the Facility after 3rd missed appointment in a 12 month period (See Termination). 

Balance Accrual
• Full payment is due at the time of your session. If you are unable to pay, tell your Provider. Your Provider and/or the Facility may offer payment plans or a sliding scale. If not, your Provider may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.
 

Administrative Fees
• Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. These fees are listed in the fee agreement. Payment is due in advance.
 

Insurance Benefits
We bill your primary and secondary insurance; please contact your insurance with any questions about coverage. You authorize the Facility to bill your insurance for any services rendered by the facility and authorize the insurance company and any third party payers to pay the Facility directly for any services rendered.

Before starting therapy, you should confirm with your insurance company if:
• Your benefits cover the type of therapy you will receive;
• Your benefits cover in-person and telehealth sessions;
• You may be responsible for any portion of the payment; and
• Your Provider is in-network or out-of-network.

Sharing Information with Insurance Companies
• If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.

Covered and Non-Covered Services
• When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance. This may include any forms that you may ask your provider to complete. See Fee Agreement.
• When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider will tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.
 

Payment Methods
• The practice encourages clients to keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.
 

RANDOM DRUG SCREENING

The practice may require a client provide a random drug screen. This is applicable to those in a medication assisted treatment (MAT) program at the Facility but does not exclude other clients who obtain treatment at the facility. 

• You may be required to provide a urine, blood sample/testing, breath, or mouth swab. The testing may be completed by a third party.
• You must be able to perform the testing within 24 hours of the request
• You must inform your Provider of any substances, licit or illicit, that may be found during the screening.

• You will be required to meet with the Provider if there is an abnormal screening. 

DESTRUCTION OF PROPERTY

The client is responsible for any and all destruction to Facility property or other property  belonging to others that may be in the Facility. By signing this form, the client agrees to these terms of liability and agrees to reimburse the Facility or other individuals for any property destruction and/or damage. 

TERMINATION

Length of Treatment can vary for each client and termination of services can come at different times due to various reasons. If you miss 3 consecutive appointments in a 12 month period without notifying or making arrangements in advance, your provider may consider your Treatment discontinued. Other factors can also contribute to termination of treatment including, but not limited to payment, insurance, etc. Your provider will offer a list of alternative providers that you can follow up with. 

COMPLAINTS
If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services.
• You can file a complaint by contacting the Practice using the following information:
Zalfi
1311 W 96th St Ste 110, Indianapolis, IN 46260
contact@zalfi.org
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.         
• The Practice will not retaliate against you for filing a complaint.

Consent for treatment may be amended periodically. All changes are applicable to the consent for treatment and a copy may be obtained by contacting the Practice or by viewing a copy on the website, www.zalfi.org . 

For Emergencies: Call 911

Suicide/Crisis Hotline: 988 or 1-800-273-8255