Lutheran Counseling Services - Hands of Hope America
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.

Client health records contain personal information about the client and their health. This information, which may identify the client and relates to their past, present or future physical or mental health or condition and related health care services, is referred to as Protected Health Information or PHI. This Notice of Privacy Practices describes how Lutheran Counseling Services may use and disclose the client PHI in accordance with applicable law. It also describes client rights regarding how they may gain access to and control PHI.

LCS is required by law to maintain the privacy of PHI and to provide clients with notice of our legal duties and privacy practices with respect to PHI. LCS is required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide clients with a copy of the revised Notice of Privacy Practices by mail or in person at the time of appointment.

How LCS may use and disclose health information about clients:

For Treatment: The client’s PHI may be used and disclosed for the purpose of providing, coordinating, or managing the client’s health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with client’s authorization.

For Payment: LCS may use or disclose PHI so that we can receive payment for the treatment of services provided to the client. Examples of payment related activities are: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.


Required by Law: Under the law, LCS must make disclosures of the client’s PHI to the client (or legal guardian) upon request. In addition, LCS must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining LCS’ compliance with Privacy Laws.

The following is a list of the categories of uses and disclosures permitted by HIPPA without an authorization:
  • Abuse and Neglect
  • Emergencies
  • National Security
  • Judicial Proceedings
  • Law Enforcement
  • Public Safety (duty to warn)
Without Authorization: Applicable law and ethical standards permit us to disclose information about the client without the client’s authorization only in a limited number of other situations. The types of uses and disclosures that may be made without client’s authorization are those that are:
  • Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the marriage and family licensing board or the Health Department)
  • Required by court order
  • Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with client’s written authorization, which may be revoked by the client at any time.
Client Rights regarding PHI:
  • Right of access to inspect and copy. Client’s have the right, which may be restricted only in exceptional circumstances to inspect and copy PHI that may be used to make decisions about client care. Client’s rights to inspect and copy will only be restricted only in those situations where there is compelling evidence that access would cause serious harm to the client. LCS may charge a reasonable, cost-based fee for copies.
  • Right to amend. If a client feels that the PHI that LCS has about the client is incorrect or incomplete, you may ask LCS to amend the information although LCS is not required to agree to the amendment.
  • Right to an Accounting of Disclosures: Clients have the right to request an accounting of the disclosures that LCS makes to PHI. LCS may charge a reasonable fee if disclosures are requested more than once during a 12-month period.
  • Right to Request Restrictions: Clients have the right to request a restriction or limitation on the use or disclosure of the PHI for treatment, payment, or health care operations. LCS is not required to agree to client’s request.
  • Right to request confidential communication: Clients have the right to request that LCS communicates with clients in a certain way or at a certain location.
  • Right to copy this notice. Clients have a right to a copy of this notice.
  • Electronic Transaction Standards
Complaints: If you believe that the client’s privacy rights have been violated and wish to file a complaint with our office, you have the right to file a complaint in writing to us at: Lutheran Counseling Services, 1505 Orchid Avenue, Winter Park, FL 32789. You may also send a written complaint to the Secretary of Health and Human Services at: 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling (202)619-0257. You have specific rights under the privacy rule. LCS will not retaliate against a client for exercising their right to file a complaint.

I acknowledge that I have read and understand the above information.
Clear Signature
Clicking SUBMIT will take you to the next form that is required.