MCS Counseling Center

7545 Centurion Parkway, Suite 106 Jacksonville, FL 32256

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. OUR PLEDGE REGARDING HEALTH INFORMATION

We understand that health information about you and the care you receive is personal. We are committed to safeguarding your Protected Health Information (PHI). PHI includes the information we maintain in records regarding the care and services you receive from our practice that can identify you. This includes information about your past, present, or future physical or mental health or condition, the health care services provided to you, and payment for those services.

We maintain these records to provide you with quality care, operate our practice effectively, and comply with applicable legal requirements. This Notice applies to all records of your care created or maintained by MCS Counseling Center. It explains how we may use and disclose your health information, describes your rights regarding the PHI we maintain about you, and outlines our legal responsibilities for protecting your information.

We are required by law to:

• Maintain the privacy of your Protected Health Information (PHI).

• Provide you with this Notice of our legal duties and privacy practices regarding your health information.

• Follow the terms of the Notice currently in effect.

• Provide any additional notice required by law if we create or maintain records protected under 42 C.F.R. Part 2.

We reserve the right to revise the terms of this Notice at any time. Any revisions will apply to all PHI we maintain, including information created before the revision. The current version of this Notice will be available in our office, on our website, and through the client portal whenever changes are made.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe the different ways we may use and disclose your Protected Health Information (PHI). For each category of uses or disclosures, we explain what we mean and provide examples. Not every possible use or disclosure is listed; however, all permitted uses and disclosures will fall within one of these categories.

Generally, use of PHI means sharing, applying, utilizing, examining, or analyzing information within our practice. Disclosure of PHI means releasing, transferring, giving, or otherwise revealing it to a person or organization outside our practice.

Uses and Disclosures Related to Treatment, Payment, or Healthcare Operations Do Not Require Your Prior Written Authorization

Federal privacy regulations permit healthcare providers who have a direct treatment relationship with a patient or client to use or disclose Protected Health Information without the patient's written authorization for purposes of treatment, payment, or healthcare operations.

For Treatment

We may use your PHI within our practice to provide you with mental health treatment. This includes consultation with clinical supervisors, treatment team members, or other licensed healthcare professionals involved in your care. We may also disclose your PHI to physicians, psychiatrists, psychologists, licensed mental health professionals, and other healthcare providers involved in your treatment or coordinating your care.

For example, if one of our clinicians consults with another licensed healthcare provider regarding your condition, we may use or disclose your PHI as necessary to assist with diagnosis, treatment planning, coordination of care, or referral.

If your records are protected under 42 C.F.R. Part 2, certain uses and disclosures otherwise permitted by HIPAA for treatment, payment, and healthcare operations may be limited by the stricter requirements of those regulations. Information disclosed pursuant to those regulations may be subject to redisclosure by the recipient and may no longer be protected under federal privacy standards.

Disclosures made for treatment purposes are not subject to the HIPAA "minimum necessary" standard because healthcare providers generally require complete information to provide safe and effective care. Treatment includes, among other things, coordination and management of healthcare, consultation between providers, and referrals from one healthcare provider to another.

To Obtain Payment for Treatment

We may use and disclose your PHI to bill and collect payment for services we provide.

For example, we may submit claims to your insurance company or health plan to obtain payment for healthcare services. We may also disclose your PHI to business associates, including billing companies, claims processing companies, clearinghouses, and other organizations that assist us with payment processing or healthcare operations.

Healthcare Operations

We may use and disclose your PHI to support the efficient operation of our practice.

Examples of healthcare operations include quality improvement activities, clinical supervision, staff training, licensing and accreditation activities, audits, compliance reviews, administrative services, legal consultation, risk management, and other business functions necessary to operate our practice.

We may also use HIPAA-compliant technology, including secure electronic health records, secure documentation tools, and secure transcription technology, to assist with clinical documentation and healthcare operations. These technologies are used only to support healthcare services and do not replace the professional judgment of your provider.

Lawsuits and Disputes

If you are involved in a lawsuit or legal proceeding, we may disclose PHI in response to a valid court order or other lawful process, as permitted or required by applicable law.

We may also disclose health information about a minor child in response to a subpoena, discovery request, or other lawful process if the legal requirements for disclosure have been satisfied.

However, if records are protected under 42 C.F.R. Part 2, those records, or testimony relating to their contents, may not be used or disclosed in civil, criminal, administrative, or legislative proceedings unless you provide specific written authorization or a court issues an order that complies with 42 C.F.R. Part 2.

Emergency Situations

Your authorization is not required if emergency treatment is needed and obtaining your consent is not possible.

If we attempt to obtain your consent but you are unable to communicate with us—for example, because you are unconscious or experiencing a medical emergency—and we reasonably believe you would consent if you were able to do so, we may use or disclose your PHI as necessary to provide emergency treatment.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

Psychotherapy Notes

Some of our providers maintain psychotherapy notes, as that term is defined in 45 C.F.R. § 164.501. Psychotherapy notes receive additional protection under HIPAA and are maintained separately from the medical record.

Any use or disclosure of psychotherapy notes requires your written authorization unless the use or disclosure is:

a) For your treatment.

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

c) For our defense in legal proceedings brought by you.

d) For use by the Secretary of the U.S. Department of Health and Human Services to investigate our compliance with HIPAA.

e) Required by law, provided the use or disclosure is limited to the requirements of that law.

f) Required by law for certain health oversight activities related to the originator of the psychotherapy notes.

g) Required by a coroner or medical examiner performing duties authorized by law.

h) Necessary to help prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Substance Use Disorder (SUD) Counseling Notes

We may also maintain Substance Use Disorder (SUD) counseling notes, which are notes recorded by a substance use disorder provider documenting the contents of a counseling session.

Any use or disclosure of these notes requires your separate written authorization. This authorization may not be combined with a consent for other types of records.

You may revoke your authorization at any time, except to the extent that we have already acted in reliance on your authorization.

Marketing Purposes

We do not use or disclose your Protected Health Information for marketing purposes without your written authorization.

Sale of Protected Health Information

We do not sell your Protected Health Information.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION

Subject to certain limitations under applicable law, we may use and disclose your Protected Health Information (PHI) without your authorization for the following purposes:

When required by law. We may use or disclose your PHI when required by federal, state, or local law, provided the use or disclosure complies with and is limited to the applicable legal requirements.

Public health activities. We may disclose your PHI for public health activities, including reporting suspected child abuse, abuse, neglect, or exploitation of an elderly person or vulnerable adult, or when necessary to prevent or reduce a serious threat to the health or safety of an individual or the public.

Serious threat to health or safety. We may use or disclose your PHI if we determine that disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or the health or safety of another person.

Health oversight activities. We may disclose your PHI to health oversight agencies for activities authorized by law, including audits, investigations, inspections, licensure, and other oversight activities.

Judicial and administrative proceedings. We may disclose your PHI in response to a court order, administrative order, subpoena, discovery request, or other lawful process, as permitted or required by applicable law.

Law enforcement. We may disclose your PHI to law enforcement officials when permitted or required by law, including reporting crimes that occur on our premises or complying with other lawful requests.

Coroners and medical examiners. We may disclose PHI to coroners or medical examiners when necessary for them to carry out duties authorized by law.

Research. We may use or disclose PHI for research purposes when permitted by law and when appropriate privacy protections have been implemented. Research involving PHI is subject to applicable federal and state confidentiality requirements and institutional review processes when required.

Specialized government functions. We may disclose PHI for certain specialized government functions, including military activities, national security and intelligence activities, protective services for the President of the United States, or correctional institution activities, when permitted or required by law.

Workers' compensation. We may disclose PHI as necessary to comply with workers' compensation or similar programs established by law.

Business associates. We may disclose PHI to business associates that perform services on behalf of our practice, including billing services, information technology providers, electronic health record vendors, legal and accounting professionals, and other organizations that assist us in providing quality care or operating our practice. We require all business associates to appropriately safeguard your PHI in accordance with applicable law.

Appointment reminders and healthcare-related communications. We may use or disclose your PHI to contact you regarding appointments, scheduling, billing matters, treatment recommendations, available services, or other healthcare-related information. Communications may occur by telephone, voicemail, secure client portal, email, or text message, as appropriate.

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

Disclosures to Family Members, Friends, or Others

We may disclose your Protected Health Information (PHI) to a family member, friend, or another person you identify as being involved in your care or payment for your healthcare unless you object, in whole or in part. If you are unable to agree or object due to an emergency or your condition, we may determine whether the disclosure is in your best interest and may disclose only the information directly relevant to that person's involvement in your care or payment for your care.

Fundraising

If we intend to use or disclose records protected under 42 C.F.R. Part 2 for fundraising purposes, we will provide you with a clear and conspicuous opportunity to opt out before any such use or disclosure occurs.

VI. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

You have the following rights regarding your Protected Health Information (PHI):

Your Right to Request Restrictions on Uses and Disclosures

You have the right to request restrictions on certain uses or disclosures of your PHI for treatment, payment, or healthcare operations. We are not required to agree to your request, but we will consider all reasonable requests. If we do agree, we will comply with the restriction unless disclosure is required by law or necessary to provide emergency treatment.

Your Right to Request Restrictions for Services Paid Out-of-Pocket in Full

You have the right to request that we not disclose PHI to your health plan for payment or healthcare operations if the information relates solely to a healthcare item or service that you (or someone on your behalf) have paid for completely out-of-pocket. We will comply with this request unless disclosure is otherwise required by law.

Your Right to Request Confidential Communications

You have the right to request that we communicate with you in a specific way or at a specific location. For example, you may request that we contact you by a particular telephone number, email address, mailing address, or other reasonable method. We will accommodate reasonable requests whenever possible.

Your Right to Inspect and Receive a Copy of Your PHI

With the exception of psychotherapy notes, SUD counseling notes (when applicable), and certain records excluded by law, you have the right to inspect and obtain an electronic or paper copy of your medical record and other PHI maintained by our practice.

We will respond to your written request within the time required by applicable law. We may charge a reasonable, cost-based fee for copies or summaries of your records when permitted by law.

Your Right to Receive an Accounting of Disclosures

You have the right to request an accounting of certain disclosures of your PHI made by our practice for purposes other than treatment, payment, healthcare operations, or disclosures you authorized.

We will respond within the time required by applicable law. The accounting generally includes disclosures made during the previous six years unless you request a shorter period.

You also have the right to request an accounting of disclosures involving substance use disorder records protected under 42 C.F.R. Part 2, when applicable.

Your Right to Request an Amendment

If you believe information contained in your PHI is incorrect or incomplete, you have the right to request that we amend your record.

We may deny your request when permitted by law but will provide a written explanation of the reason for the denial within the time required by applicable law.

Your Right to Receive a Copy of this Notice

You have the right to receive a paper copy of this Notice at any time, even if you previously agreed to receive it electronically. You may also request an electronic copy.

VII. COMPLAINTS

If you believe your privacy rights have been violated, or if you disagree with a decision we have made regarding access to your PHI, you may file a complaint with our Privacy Officer using the contact information provided below.

You may also file a complaint with the:

U.S. Department of Health and Human Services Office for Civil Rights

Filing a complaint will not affect your care, and we will not retaliate against you for exercising your rights.

VIII. CONTACT INFORMATION

If you have questions about this Notice, would like additional information regarding our privacy practices, or wish to file a privacy complaint, please contact:

Steven Montesinos, LMHC
Privacy Officer

MCS Counseling Center 7545 Centurion Parkway, Suite 106 Jacksonville, FL 32256

Phone: 904-701-4662

Email: steven@mcsjax.com

Website: www.mcsjax.com

EFFECTIVE DATE OF THIS NOTICE

Originally Effective: May 6, 2018

Last Revised: August 7, 2026

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Under the Health Insurance Portability and Accountability Act (HIPAA), you have certain rights regarding the use and disclosure of your Protected Health Information.

By checking the box below, you acknowledge that you have received or been provided access to MCS Counseling Center's Notice of Privacy Practices.

Document Version: August 2026

As a current or prospective client, you understand that you can text us STOP at any time to opt out of receiving SMS text messages from us. You can text us HELP at any time to receive help.

You understand that the messaging frequency may vary.

Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes. All policies are followed as per CTIA guidelines 5.2.1. At any time if you want your information to be removed, you can contact us via our email address or regular mail.

MCS Counseling Center

7545 Centurion Parkway, Suite 106 Jacksonville, FL 32256

INFORMED CONSENT FOR PSYCHOTHERAPY, FINANCIAL POLICIES, AND PRACTICE INFORMATION

WELCOME

You (or your family member) are starting counseling with a provider at MCS Counseling Center. We're glad you're here.

This document explains how therapy works and outlines our office policies. Please read it carefully. If you have any questions before signing or at any time during your care, please contact our office.

ABOUT THERAPY

Therapy is a professional relationship focused on helping you improve your mental health and work toward your personal goals.

Therapy is most effective when you actively participate in the process. At times, discussing difficult experiences, thoughts, or emotions may feel uncomfortable. This is a common part of therapy and often contributes to meaningful growth.

While we cannot guarantee specific outcomes, our providers are committed to providing ethical, compassionate, and evidence-based care to support your goals.

Our services are outpatient mental health services and are not a substitute for emergency, crisis, or inpatient care.

Services are provided based on the client's location at the time of each appointment. For Telehealth sessions, you must be physically located in a state where your provider is licensed to practice at the time of the session. If you are not located in a state where your provider is licensed, your appointment may need to be canceled or rescheduled.

CONFIDENTIALITY

Your privacy is very important to us. Information shared during therapy is kept confidential and will not be disclosed without your permission except when permitted or required by applicable federal or state law or professional ethics.

Examples include:

• If there is a risk of serious harm to yourself or another person, including concerns about suicide or violence.

• If there is suspected abuse, neglect, or exploitation of a child, elderly person, or vulnerable adult.

• If disclosure is required by law, including a valid court order.

• When information is needed for treatment, payment, or healthcare operations, such as consulting with other professionals involved in your care or submitting claims to your insurance company.

If you have questions about confidentiality or how your information may be used or disclosed, please contact our office. Our Notice of Privacy Practices provides additional details about your privacy rights and how we protect your health information.

APPOINTMENTS AND CANCELLATIONS

To help us provide timely and consistent care, we ask that appointments be canceled or rescheduled at least 24 hours in advance.

Appointments that are missed or canceled with less than 24 hours' notice are subject to a $50 late cancellation/no-show fee. This fee is not covered by insurance and will be charged to the payment method on file.

If you arrive late, your session may be shortened so that the provider can remain on schedule.

Scheduling changes, cancellations, and other administrative requests must be made through our office during normal business hours. Messages sent only to your provider may not be received in time to avoid a late cancellation fee.

FEES & PAYMENTS

Self-pay fees vary depending on the provider and service selected. Current fees generally range from $45–$185 per session or service.

Your specific fees will be provided before services begin.

Payment for services will be processed using the payment method on file. You are responsible for payment of all services received, regardless of insurance coverage. Fees may differ if you use insurance or qualify for a discounted self-pay rate.

If a payment is declined or returned, a $10 returned payment fee may be assessed.

INSURANCE AND BILLING

We accept several insurance plans; however, participation varies by provider and insurance plan.

We make reasonable efforts to verify insurance eligibility and benefits before services begin. Insurance companies may change benefits, eligibility, or payment determinations at any time. You remain responsible for confirming your coverage, understanding your benefits, providing accurate and current insurance information, notifying us of any insurance changes, and paying any costs not covered by your insurance, including copays, deductibles, coinsurance, non-covered services, and denied claims.

TRICARE

Some providers are TRICARE-certified but are not participating network providers. Depending on your plan, you may be responsible for deductibles, cost-share amounts, or other out-of-pocket expenses.

HEADWAY

Some providers bill through Headway.

If Headway applies to your care, you will receive emails directly from Headway to create your account and provide any required insurance or payment information.

While we are happy to answer general questions, Headway independently manages insurance billing, payment processing, reimbursement decisions, and billing determinations. We do not control these decisions.

If you have concerns regarding Headway billing, please contact our office, and you may also contact Headway directly at https://headway.co/

PAYMENT METHOD REQUIRED

A valid payment method must remain on file throughout treatment.

If your payment method is declined and is not updated after reasonable attempts to contact you, future appointments may be postponed or canceled until the account is brought current. Repeated payment issues may result in discontinuation of services.

OUT-OF-NETWORK & SELF-PAY

If your provider is not in-network with your insurance plan, we can provide a superbill that you may submit to your insurance company for possible reimbursement. Reimbursement is determined by your insurance company and cannot be guaranteed.

Payment is due at the time services are provided and will be processed using the payment method on file.

Some clients may qualify for discounted self-pay rates. Please contact our office for current discounted self-pay options, if available.

GOOD FAITH ESTIMATE

If you are receiving services without using insurance (self-pay), federal law gives you the right to receive a Good Faith Estimate explaining the expected cost of your care before services begin.

STAFF INTERNS AND CLINICAL SUPERVISION

Some providers at MCS Counseling Center are Registered Mental Health Counselor Interns working toward independent licensure.

These clinicians have completed graduate-level training, hold a provisional state license, and provide services under the supervision of a fully licensed clinician as required by Florida law.

If you have any questions or concerns regarding your care, please contact our office.

COMMUNICATION

You may contact our office by:

Phone: 904-701-4662

Secure Client Portal: www.mcsjax.com

We strive to return messages within two business days. Messages received outside normal business hours are considered received on the next business day.

Scheduling changes, cancellations, billing questions, insurance questions, and other administrative matters should be directed to our office. Communication with your provider alone does not guarantee that administrative requests will be received or processed.

Emergency Services

MCS Counseling Center does not provide emergency or crisis services.

If you are experiencing a medical or mental health emergency, call 911 or go to your nearest emergency room immediately.

TECHNOLOGY & TOOLS

We use secure, HIPAA-compliant electronic systems to document your care, communicate with clients, and provide Telehealth services.

With your consent, some providers may use secure AI-assisted transcription or documentation tools to support clinical documentation. When these tools are used, sessions may be briefly recorded solely for transcription purposes. Recordings are automatically deleted after transcription is complete and are not retained as part of your medical record.

These tools are HIPAA-compliant and are used only to assist with clinical documentation. They do not replace your provider's professional judgment.

By signing this informed consent, you authorize the use of AI-assisted transcription and documentation tools, including the temporary recording of sessions solely for transcription purposes as described above.

If you have any questions regarding the use of these tools, please contact our office before signing or at any time during your treatment.

You may revoke this consent at any time by notifying our office in writing. Revocation will apply only to future sessions and will not affect documentation already completed using your prior consent.

SOCIAL MEDIA

To protect your privacy and maintain appropriate professional boundaries, we do not accept friend requests, follow requests, or other personal connections from current clients on personal social media accounts.

You are welcome to follow or interact with our professional social media pages. Please be aware that your privacy settings may allow others to see that you follow or engage with our practice.

If information from social media becomes relevant to your care, you are welcome to discuss it during therapy. We will not access or monitor your social media accounts without your permission.

MINORS

If you are under the age of 18, your parent or legal guardian may have the legal right to receive information regarding your treatment, as permitted by applicable law.

Whenever appropriate, we will discuss confidentiality expectations with both you and your parent or guardian and will make reasonable efforts to protect your privacy while complying with legal and ethical obligations.

HEALTH AND SAFETY

If you are experiencing symptoms of a contagious illness or believe you may have been exposed to one, please contact our office before your appointment. When appropriate, we may recommend rescheduling your appointment or converting it to a telehealth session if available.

DISCONTINUATION OF SERVICES

Therapy may end for a variety of reasons, including when treatment goals have been met, you choose to discontinue services, you transfer care to another provider, or a different level or type of care is more appropriate.

We may also discontinue services due to circumstances such as:

• Repeated missed or late-canceled appointments.

• Failure to maintain payment arrangements or resolve outstanding balances.

• Inappropriate, threatening, abusive, or disrespectful behavior toward providers or staff.

• Circumstances in which we are no longer able to provide appropriate care.

When appropriate, we will make reasonable efforts to discuss the discontinuation of services and provide referral information upon request.

If you do not schedule or attend an appointment for eight (8) consecutive weeks, your chart may be considered inactive and your episode of care may be closed. Returning to treatment after that time will depend on provider availability and may require placement on a waitlist or completion of updated intake paperwork.

QUESTIONS ABOUT YOUR CARE

We encourage you to ask questions at any time regarding your treatment, our policies, billing, privacy practices, or any other aspect of your care.

Questions regarding scheduling, billing, insurance, practice policies, or administrative matters should be directed to our office so we can assist you promptly.

ACKNOWLEDGEMENT OF INFORMED CONSENT

By signing below, you acknowledge that:

• You have read and understand this Informed Consent for Psychotherapy and Practice Policies.

• You have had the opportunity to ask questions about these policies and have received answers to your satisfaction.

• You understand the nature and purpose of outpatient psychotherapy, including its potential benefits and limitations.

• You understand your financial responsibilities, including fees, payment policies, insurance responsibilities, and cancellation policies.

• You understand the limits of confidentiality and have been informed of situations in which disclosure of information may be permitted or required by law.

• You consent to the use of secure electronic systems, including AI-assisted documentation tools when applicable, as described in this document.

• You understand that you may withdraw consent for AI-assisted transcription by notifying our office in writing, and that doing so will apply only to future sessions.

• You understand that MCS Counseling Center does not provide emergency or crisis services and know to call 911 or go to the nearest emergency room during an emergency.

• You understand that you may request additional information or clarification regarding these policies at any time by contacting our office.

By providing your electronic signature below, you voluntarily consent to receive psychotherapy services from MCS Counseling Center under the terms described in this document.

Document Version: August 2026