NOTICE OF PRIVACY PRACTICESTransitions Behavioral HealthYour Information. Your Rights. Our Responsibilities.This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.Your RightsWhen it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.You have the right to:Get a copy of your paper or electronic medical recordYou can see or get a copy of your health information. We’ll provide it within 30 days and may charge a reasonable fee.Ask us to correct your medical recordIf you think something is wrong or missing, you can ask us to correct it. If we deny your request, we’ll explain why in writing.Request confidential communicationsYou can ask us to contact you in a specific way or at a different address. We’ll agree to all reasonable requests.Ask us to limit what we use or shareYou can ask us not to use or share certain information for treatment, payment, or operations. We may decline if it affects your care. If you pay out-of-pocket in full, you can ask us not to share that information with your insurer unless required by law.Get a list of those with whom we’ve shared informationYou can request a record of who we’ve shared your information with and why, for up to six years, for any non-routine or required by law disclosures. This list won’t include disclosures for treatment, payment, authorized release, coordinating care, or health-care operations.Get a copy of this privacy noticeYou can ask for a paper copy at any time, even if you agreed to get it electronically.Choose someone to act for youIf you’ve given someone medical power of attorney or have a legal guardian, that person can exercise your rights for you.File a complaint if you feel your rights are violatedYou can contact us or the U.S. Department of Health & Human Services to file a complaint. We will not retaliate against you.Your ChoicesFor certain health information, you can tell us your preferences about what we share. We will make reasonable efforts to follow your wishes when possible and permitted by law.You have both the right and choice to tell us to:Share information with your family, close friends, or others involved in your careShare information in a disaster relief situationInclude your information in a facility directory (if applicable)
If you are unable to tell us your preferences — for example, during a crisis or emergency — we may share information if we believe it is in your best interest or required by law, such as to prevent harm or ensure safety.In these cases, we never share your information unless you give us written permission:Marketing purposesSale of your informationMost sharing of psychotherapy notes
FundraisingWe may contact you for fundraising efforts, but you can ask us not to contact you again.Our Uses and DisclosuresWe typically use or share your health information in the following ways:Treat youWe can use your health information and share it with other professionals who are treating you.Example: A therapist discusses your care plan with your primary care provider.Run our organizationWe can use and share your 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 coordinate services.Bill for your servicesWe 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 insurance plan so it will pay for your services.How else can we use or share your information?We are allowed or required to share your information in other ways—usually for public good, such as public health or research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, visit www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.Help with public health and safety issuesWe can share health information about you to help with:Preventing diseaseReporting suspected abuse, neglect, or domestic violenceReporting adverse reactions to medications or product recallsPreventing or reducing a serious threat to anyone’s health or safety
Do researchWe can use or share your information for approved health research.Comply with the lawWe will share information if state or federal laws require it, including with the Department of Health & Human Services to confirm compliance with federal privacy laws.Respond to organ and tissue donation requestsWe can share health information about you with organ procurement organizations.Work with a medical examiner or funeral directorWe can share information with a coroner, medical examiner, or funeral director as needed.Address workers’ compensation, law enforcement, and other government requestsWe can use or share health information:For workers’ compensation claimsFor law enforcement purposesWith health oversight agencies for activities authorized by lawFor special government functions such as military or national security
Respond to lawsuits and legal actionsWe can share health information about you in response to a court or administrative order, or in response to a subpoena.Our ResponsibilitiesWe are required by law to maintain the privacy and security of your protected health information.We will notify you promptly if a breach occurs that may compromise your information.We must follow the duties and privacy practices described in this notice and provide you with a copy.We will not use or share your information other than as described here unless you give us written permission. You may revoke that permission at any time in writing.
Redisclosure NoticeOnce your health information is disclosed to another person or organization, it may no longer be protected by this Notice or by the HIPAA Privacy Rule.Changes to the Terms of This NoticeWe may 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 website.Contact InformationCompliance Officer (Privacy Contact):
Transitions Behavioral Health
Phone: 513-832-2884 ext. 121
Email: admin@transitions-bh.comYou may also contact the U.S. Department of Health and Human Services, Office for Civil Rights at:
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775
www.hhs.gov/ocr/privacy/hipaa/complaintsEffective Date: November 1, 2025
TRANSITIONS BEHAVIORAL HEALTHCONSENT AND TERMS FOR TEXT/SMS & MMS MESSAGINGClient Name: _______________________________________________Client Date of Birth: _______________________________________Parent/Guardian Name, if applicable: _____________________________Transitions Behavioral Health (“Transitions”) values clear and timely communication with our clients, parents, guardians, and caregivers. To assist with appointment coordination and other agency-related communications, Transitions offers optional communication through SMS/text messaging, MMS messaging, telephone calls, and email.Participation in text messaging is voluntary. Please review this Consent and Terms for Text/SMS & MMS Messaging in its entirety before deciding whether you wish to participate.1. PROGRAM DESCRIPTION AND PURPOSEBy providing your consent, you authorize Transitions Behavioral Health to communicate with you through SMS and/or MMS messages at the mobile telephone number you provide.Messages may include, but are not limited to:Appointment confirmations and reminders;Notifications regarding incidents, illness, injury, or medical emergencies;Agency closures, delays, early releases, schedule changes, and other operational updates;Reminders regarding case-related needs, forms, documents, appointments, or activities that need to be completed;General agency announcements, policy notifications, and administrative communications;Requests for you to contact a Transitions staff member regarding your or your child’s services; andOther agency-related communications as reasonably necessary.Message frequency varies depending upon appointments, scheduling, agency operations, and individual service needs.Text messaging is intended primarily for administrative, scheduling, notification, and general communication purposes. Text messaging should not be used as the primary method for discussing detailed treatment matters, clinical concerns, treatment recommendations, or other sensitive protected health information (“PHI”). When appropriate, Transitions may request that such matters be discussed by telephone, secure communication, email when appropriate, or during an in-person meeting.2. CONSENT TO PARTICIPATEParticipation in Transitions' text messaging program is voluntary.Your consent begins on the date you sign this form and continues until you withdraw your consent or otherwise opt out of receiving messages.Choosing not to participate, or choosing to withdraw your consent at a later time, will not affect your eligibility to receive services, treatment, or other benefits to which you are otherwise entitled.3. BENEFITS OF TEXT COMMUNICATIONText messaging may provide a convenient way to:Receive appointment reminders and confirmations;Receive timely notice of schedule or agency changes;Receive important agency notifications;Receive reminders about outstanding case-related items or activities; andMaintain routine administrative communication with Transitions.These communications may assist you in managing your or your child’s appointments, services, and other agency-related responsibilities.4. PRIVACY AND SECURITY RISKSSMS and MMS text messaging are not always secure methods of communication.Messages may travel through cellular networks, telecommunications providers, mobile devices, and other systems that are not owned or controlled by Transitions. As a result, Transitions cannot guarantee the confidentiality or security of information contained in a text message.By consenting to text messaging, you understand that:A message may potentially be viewed by someone other than you;Messages may remain stored on your mobile device;Individuals with access to your telephone may be able to view received messages;A lost, stolen, shared, or unsecured device may create additional privacy risks;Your cellular carrier or other technology providers may have access to certain information related to the communication; andElectronic messages may occasionally be delayed, misdirected, intercepted, or not delivered.If you share your mobile telephone with another person or believe that others may have access to your messages, you should carefully consider whether text messaging is an appropriate communication method for you.Carriers are not liable for delayed or undelivered messages.5. PROTECTED HEALTH INFORMATIONReceiving or sending text messages involving Transitions may create a risk that protected health information (“PHI”) could be disclosed to an unauthorized individual.Clients, parents, guardians, and caregivers are asked not to send detailed PHI, medical records, diagnoses, treatment information, photographs containing sensitive health information, or other confidential clinical information through the general Transitions texting service.If you send sensitive information through text messaging, Transitions may contact you through another appropriate communication method to continue the conversation.6. MESSAGE AND DATA RATESMessage and data rates may apply.Any charges associated with SMS/MMS messages, telephone calls, mobile data, or other communications are determined by your wireless carrier and mobile service plan. Transitions is not responsible for charges assessed by your wireless carrier.7. HOW TO OPT OUTYou may withdraw your consent to receive text messages at any time.Reply STOP to opt out.After submitting a STOP request, you may receive a final confirmation message indicating that you have been unsubscribed. After your opt-out request has been processed, Transitions will discontinue nonessential SMS/MMS communications to that number unless you subsequently provide consent to enroll again.You may also withdraw your consent by contacting Transitions Behavioral Health.8. HELP AND SUPPORTReply HELP for assistance.For additional assistance regarding the messaging program, please contact Transitions Behavioral Health using the agency's designated support email:Email: _________________________________________________Questions specifically concerning your care or your child’s care should be directed to your Transitions representative through the appropriate communication method.9. EMERGENCIESThe Transitions text messaging service is not an emergency service and should not be used to request emergency assistance.If you or another person is experiencing a medical or life-threatening emergency, call 911 or seek immediate emergency assistance.Do not rely on a text message to Transitions to communicate an emergency.10. COMMUNICATION METHODSBy consenting, you understand that Transitions may communicate with you through SMS and MMS text messaging for the purposes described in this document.Other communications concerning your or your child’s services may occur through telephone calls, email, face-to-face meetings, secure electronic systems, written correspondence, or other communication methods determined to be appropriate based on the nature of the information.11. MOBILE TELEPHONE RESPONSIBILITYBy enrolling in text messaging, you represent that you are authorized to use the mobile telephone number provided below and to consent to receiving communications at that number.You agree to notify Transitions if:Your telephone number changes;You are no longer authorized to use the telephone number;Your telephone is lost or stolen; orYou otherwise believe continued communication to the telephone number may create a privacy or security concern.12. PRIVACY POLICYInformation regarding Transitions Behavioral Health's privacy practices and handling of personal information is available through our Privacy Policy:Privacy Policy: [INSERT DIRECT HYPERLINK TO TRANSITIONS BEHAVIORAL HEALTH PRIVACY POLICY]13. CONSENT SELECTIONMobile/Cell Phone Number: _____________________________________Please select one of the following:☐ I CONSENT. I authorize Transitions Behavioral Health to send SMS and/or MMS text messages to the mobile telephone number listed above. I acknowledge that I have read, or have had explained to me, this Consent and Terms for Text/SMS & MMS Messaging. I understand the purpose of the messaging program, potential privacy and security risks, possible charges, message frequency, and my right to withdraw consent at any time.I understand that message frequency varies, message and data rates may apply, I may reply STOP to opt out, and I may reply HELP for assistance.☐ I DO NOT CONSENT. I decline to receive communications and notifications from Transitions Behavioral Health through SMS and/or MMS text messaging. I understand that declining text messaging will not affect my or my child’s eligibility for services or other rights or benefits.Signature of Client/Parent/Legal Guardian:Printed Name:Relationship to Client, if applicable:Date: __________________________FOR AGENCY USEConsent Received By: __________________________________________Date Entered/Updated: _________________________________________Staff Initials: _______________________________________________