HIPAA Notice of Privacy Practices

A Life In Balance DBT Skills Training Group

Provider: A Life In Balance

Effective Date: January 1, 2026

This Notice describes how protected health information (PHI) about you may be used and disclosed and how you can access this information. Please review it carefully.

1. Our Commitment to Your Privacy

A Life In Balance is committed to protecting the privacy and confidentiality of your personal and health-related information. We are required by the Health Insurance Portability and Accountability Act (HIPAA) to maintain the privacy of your protected health information (PHI), provide you with this Notice, and follow the privacy practices described herein.

2. What Is Protected Health Information (PHI)

Protected Health Information includes information that:

• Identifies you or could reasonably be used to identify you, and

• Relates to your health, services received, or payment for services

This may include your name, contact information, session participation records, intake forms, payment records, and communications related to services.

3. How Your Information May Be Used & Disclosed

We may use or disclose your PHI without your written authorization for the following purposes:

A. Program Administration & Operations

• Managing enrollment, participation, attendance, and communications

• Facilitating skills training sessions and program-related coordination

• Quality assurance and internal administrative purposes

B. Payment & Billing

• Processing payments

• Communicating with billing platforms or payment processors

• Providing receipts or payment documentation

C. Legal & Safety Obligations

We may disclose information when required by law, including:

• To comply with legal obligations or court orders

• To report suspected abuse or neglect when required

• To prevent or reduce a serious threat to health or safety

4. Confidentiality in Group-Based Services

While facilitators are legally and ethically required to protect your privacy, confidentiality cannot be guaranteed in a group setting. Other participants are not legally bound by HIPAA.

You are expected to:

• Respect the privacy of other participants

• Refrain from sharing identifying or personal information disclosed in group outside of sessions

5. Your Rights Regarding Your Information

You have the right to:

• Access: Request a copy of your information

• Amend: Request corrections to your records

• Restrict: Request limits on certain uses or disclosures (may not always be granted)

• Confidential Communications: Request communications in a specific way (e.g., email only)

• Accounting of Disclosures: Request a list of certain disclosures

• Paper Copy: Request a paper copy of this Notice at any time

Requests must be submitted in writing and may be subject to reasonable limitations or fees as permitted by law.

6. Safeguards & Electronic Information

We use reasonable administrative, technical, and physical safeguards to protect your information, including:

• Secure digital storage

• HIPAA-compliant platforms for virtual services

• Limited access to authorized personnel only

Despite safeguards, no electronic system can be guaranteed to be 100% secure.

7. Changes to This Notice

We reserve the right to change this Notice at any time. Updated versions will be made available upon request and posted where appropriate. Changes apply to all information we maintain.

By signing below, I confirm that:

• I have read and understand this Virtual Skills Training Consent.

• I understand the benefits, risks, and limitations of virtual participation.

• I consent to participate in DBT skills training delivered via HIPAA-compliant virtual platforms.

• I have completed the recording acknowledgment above.

8. Questions, Concerns, or Complaints

If you have questions about this Notice or believe your privacy rights have been violated, you may contact:

Privacy Officer / Provider:

A Life In Balance

Email: nicoleperkins@alibstrong.com

Phone: 415-580-1908

You also have the right to file a complaint with the U.S. Department of Health and Human Services. Filing a complaint will not result in retaliation.

9. Acknowledgment of Receipt

By signing below, I acknowledge that:

• I have received and reviewed the HIPAA Notice of Privacy Practices.

• I understand how my information may be used and disclosed.

• I understand my rights regarding my protected health information.

I understand that acknowledgment of receipt does not require agreement with the contents of this Notice.