White Mountain
Walk-in Clinic

White Mountain Walk-in Clinic 

NOTICE OF PRIVACY PRACTICES UNDER HIPAA AND 42 C.F.R. PART 2

Effective February 13, 2026

This notice describes:

• HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

• YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

• HOW TO FILE A COMPLAINT CONCERNING A VIOLATION OF THE PRIVACY OR SECURITY OF YOUR HEALTH INFORMATION, OR OF YOUR RIGHTS CONCERNING YOUR INFORMATION

YOU HAVE A RIGHT TO A COPY OF THIS NOTICE (IN PAPER OR ELECTRONIC FORM) AND TO DISCUSS IT WITH GARRETT YOUNG, CORPORATE COUNSEL AT garrett@highpointcounseling.com OR BY CALLING THE CLINIC AT (307) 212-8014 option 2 IF YOU HAVE ANY QUESTIONS.

Your personal information is important and protected by law. This notice describes how your protected health information, including mental and substance use disorder health information, may be used and disclosed and how you can get access to this information.  This notice also applies to High Point Counseling which may provide billing, scheduling, mental health, counseling, and other services involving the use of your personal information. 

Please review it carefully.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

OVERVIEW OF RIGHTS

You have the right to: 

• Get a copy of your paper or electronic medical record

• Correct your paper or electronic medical record

• Request confidential communication

• Ask us to limit the information we share

• Get a list of those with whom we’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

• Revoke written consent

EXPLANATION OF RIGHTS

Get an electronic or paper copy of your medical record 

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. 

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. 

• We will agree to all reasonable confidentiality requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree to such a request unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list  of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

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 and make choices about your health information.

• We will verify that the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• 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/.

• We will not retaliate against you for filing a complaint.

Revoke written consent

• If you at any time wish to revoke your written consent to our use or sharing of your protected health information, you can notify us in writing and we will comply with such request to the extent required by law.

Your Choices

SUMMARY OF YOUR CHOICES RELATED TO HEALTH INFORMATION PRIVACY

You have some choices in the way that we use and share information as we: 

• Tell family and friends about your condition

• Provide disaster relief

• Include you in a clinic directory

• Provide mental health care

• Market our services 

• Raise funds

EXPLANATION OF YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a clinic directory

If you are not able to tell us your preference, for example if you are unconscious, we may opt to share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

We will never share your information in the following circumstances unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

SUMMARY OF OUR USES AND DISCLOSURES

We may use and share your information as we: 

• Treat you

• Run our organization

• Bill for your services

• Help with public health and safety issues

• Do research

• Comply with the law

• Respond to organ and tissue donation requests

• Work with a medical examiner or funeral director

• Address workers’ compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions

EXPLANATION OF OUR USES AND DISCLOSURES

How do we typically use or share your health information? 

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A provider treating you for an injury asks another provider about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services. 

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities. 

Example: We give information about you to your health insurance plan so it will pay for your services. 

How else can we use or share your health information? 

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as: 

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.  However, records about substance use disorders covered under 42 CFR Part 2 and records or testimony relaying the content of such records, shall not be disclosed in any civil, administrative, criminal, or legislative proceedings against you unless based on your specific written consent or court order.  Even where a court order for such records is issued, records shall only be used or disclosed after you have been given notice and an opportunity to be heard, and the court order must be accompanied by a subpoena or other legal mandate before we will disclose the records.

You may provide a single consent for all future uses or disclosures for treatment, payment, and health care operations purposes.  You may also revoke your consent as described in the “Your Rights” section of this policy.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information. 

• 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. 

• If a more strict law, like a state privacy law or 42 CFR Part 2, applies to your health information, we will comply with the more strict law.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We reserve the right to change the terms of this notice, and the changes will apply to all information we have about you. 

The new notice will be available upon request, in our office, and on our web site.

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You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. 

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. 

• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. 

• If you receive a bill that is at least $400 more than your Good FaithEstimate, you can dispute the bill. 

• Make sure to save a copy or picture of your Good Faith Estimate. 

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059. Description text goes here