Notice of Privacy Practices 

The Black Mental Health Corporation, 13110 Shaker Square, Suite C200-F, Cleveland, OH 44120, 216-512- 0321 

NOTICE OF PRIVACY PRACTICES 

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. MY PLEDGE REGARDING HEALTH INFORMATION: 

I understand that health information about you and your health care is personal. I am committed to  protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights  to the health information I keep about you and describe certain obligations I have regarding the use and  disclosure of your health information. I am required by law to: 

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect. 

• I can change the terms of this Notice, and such changes will apply to all information I have about you. The  new Notice will be available upon request, in my office, and on my website. 

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: 

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

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care  providers who have direct treatment relationship with the patient/client to use or disclose the  patient/client’s personal health information without the patient’s written authorization, to carry out the  health care provider’s own treatment, payment or health care operations. I may also disclose your protected  health information for the treatment activities of any health care provider. This too can be done without  your written authorization. For example, if a clinician were to consult with another licensed health care  provider about your condition, we would be permitted to use and disclose your person health information,  which is otherwise confidential, to assist the clinician in diagnosis and treatment of your mental health  condition. 

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 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.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a  court or administrative order. I may also disclose health information about your child in response to a  subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if  efforts have been made to tell you about the request or to obtain an order protecting the information  requested. 

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: 

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and  any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For my use in treating you. 

b. For my use in training or supervising mental health practitioners to help them improve their skills in  group, joint, family, or individual counseling or therapy. 

c. For my use in defending myself in legal proceedings instituted by you. 

d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. 

g. Required by a coroner who is performing duties authorized by law. 

h. Required to help avert a serious threat to the health and safety of others. 

2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business. 

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons: 

1. 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. 

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety. 

3. For health oversight activities, including audits and investigations. 

4. For judicial and administrative proceedings, including responding to a court or administrative order,  although my preference is to obtain an Authorization from you before doing so. 

5. For law enforcement purposes, including reporting crimes occurring on my premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law. 

7. For research purposes, including 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.

8. Specialized government functions, including, 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. 

9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI to comply with workers' compensation laws. 

10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to  contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer. 

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT. 

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you  indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The  opportunity to consent may be obtained retroactively in emergency situations. 

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

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to  use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not  required to agree to your request, and I may say “no” if I believed it would affect your health care. 

2. The Right to 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. 

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific  way (for example, home or office phone) or to send mail to a different address, and I will agree to all  reasonable requests. 

4. The Right to See and Get 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 I have about you. I  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 I may charge a reasonable, cost-based fee for  doing so. 

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

6. The Right to Correct or Update Your PHI. 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 I correct  the existing information or add the missing information. I may say “no” to your request, but I will tell  you why in writing within 60 days of receiving your request. 

7. The Right to Get 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. 

SMS PRIVACY POLICY 

Below is a basic messaging privacy policy sample. This sample may not contain all the disclosures required by  state law privacy policies or for your industry. You can also use your organization’s more comprehensive  privacy policy if it covers your messaging campaigns. 

Although you can use these samples to create your own materials, please understand that they are provided as  tools to help you understand the documentation that is being requested as part of the 10DLC campaign  registration process. They do not constitute legal guidance or serve to create an attorney-client relationship.  You should consult your own legal counsel for guidance. They may not address how your business operates,  and they are not intended to address the requirements of your law or industry requirements, and as a result,  they may not be sufficient for your purposes. We cannot advise you how to interpret the laws that govern you,  whether these forms are sufficient for your business, or where to obtain legal advice. Please note that carrier,  aggregator, and legal requirements are subject to change. As a result, you should monitor for these changes  adjust your processes and documentation accordingly. 

Messaging Privacy Policy 

Effective Date: 01/01/2026 

[THE BLACK MENTAL HEALTH CORPORATION (TBMHC)] (“we,” “us,” “our”) respects your privacy and is  committed to protecting your personal information. This Privacy Policy explains how [TBMHC] collects and  uses information about you when you opt-in to receive SMS messages from us. 

Information We Collect 

When you opt-in to receive SMS messages, we collect: 

• Your phone number 

• Consent to send SMS messages 

• Your email address 

• Your basic contact information 

• Your messaging history 

How We Collect Your Information 

We may collect your information directly from you, such as when you complete a form or contact us or  automatically, such as when you interact with our website. 

How We Use Your Information 

We use your information to: 

• Send you the SMS messages you’ve opted in to receive 

• Provide updates, promotions, or other relevant content based on your preferences • Choices and Controls 

• To operate our business 

You can opt out of receiving SMS messages at any time by replying STOP to any message we send you. You  can review our Terms [https://www.theblackmentalhealthcorporation.com] for additional information about the  opt-out process. 

To Whom We Disclose Your Information 

We do not share your personal information, phone number, or SMS consent opt-in data with third parties or  affiliates for marketing or promotional purposes.

Protection of Information 

Consumer data, including phone numbers and SMS opt-in data, will not be transferred, shared, sold, or  disclosed to any external organizations under any circumstances, except as required by law. 

Updates 

We may periodically update this privacy policy. If we make material changes that have a substantive and  adverse impact on your privacy, we will provide notice on this website prior to the change becoming effective.  We encourage you to periodically review this page for the latest information about our privacy practices. 

Contact for Messaging Privacy Questions 

If you have any questions about the Messaging Privacy Policy or the SMS program, please contact support  directly through the support contact method provided on this website. You can reach us by texting the word  HELP for support to [216-512-0321]. You may also contact us directly at [helpline@tbmentalhealth.com]. 

Consumers opt in verbally when speaking with THE BLACK MENTAL HEALTH CORPORATION staff. Staff will  read the customer the following script: "By opting in, you agree to receive messages from THE BLACK  MENTAL HEALTH CORPORATION. The types of messages that will be sent include conversational  messages." "Message and data rates may apply. Message frequency may vary. On average, 1-2 messages  per month. You can text HELP for support or more information and STOP to unsubscribe at any time." "For  more information, please refer to the attached documents for our privacy policy and terms and conditions."  These messages may include appointment scheduling, care coordination, support follow-ups, and service related responses. 

EFFECTIVE DATE OF THIS NOTICE 

This notice went into effect on September 1, 2018, Acknowledgement 

of Receipt of Privacy Notice 

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights  regarding the use and disclosure of your protected health information. By checking the box below, you are  acknowledging that you have received a copy of HIPPA Notice of Privacy Practices. 

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.