NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL AND MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

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Effective Date: 05/01/26

Last Updated: 05/01/26

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1. Our Commitment to Your Privacy

Our practice is dedicated to maintaining the confidentiality of your mental health treatment. We create a record of the care and services you receive to provide quality care and comply with legal requirements. We are required by law to maintain the privacy of your PHI and to provide you with this detailed description of our legal duties. 

2. Routine Uses and Disclosures (Treatment, Payment, & Operations)

We may use or share your PHI without your specific written authorization for the following routine healthcare purposes: 

• Treatment: We may disclose your PHI to coordinate your care. 

• Payment: We may use and disclose your PHI so that the services you receive can be billed and paid by you, an insurance company, or another third party. 

• Healthcare Operations: We may use your PHI to run our practice smoothly and ensure high-quality care. 

3. Special Protections for Psychotherapy Notes

"Psychotherapy Notes" are private notes recorded by your therapist documenting the contents of a counseling session. These notes are kept completely separate from the rest of your medical record and receive an extra layer of protection. We must obtain your specific written authorization to use or disclose your psychotherapy notes, except in rare circumstances such as defending the practice against a lawsuit brought by you, or preventing an imminent, serious threat to health or safety. 

4. Uses and Disclosures Requiring Your Explicit Authorization 

For actions outside of routine treatment, payment, or operations, we will only release your info if you sign a specific written Authorization form. You may revoke this authorization in writing at any time. Your explicit authorization is strictly required for: [2, 5]

• Marketing: We will never sell your PHI or use it for marketing purposes.

• Third Parties: Sharing progress updates with your employer, lawyer, or family members. Without Your Consent (Limits of Confidentiality) 

Federal and state laws require or permit us to share your PHI without your authorization in the following emergency or legal scenarios: 

• Child or Elder Abuse: If we suspect a child, elderly person, or vulnerable adult is being abused or neglected, we are legally mandated to report it to authorities. 

• Threat to Health or Safety: If you communicate an imminent threat of serious physical harm to yourself or an identifiable victim, we must take protective actions (e.g., notifying law enforcement or warning the victim). 

• Judicial Proceedings: If you are involved in a lawsuit and a judge issues a court order or subpoena, we may be required to release relevant psychological records. 

• Workers' Compensation: If you file a workers' compensation claim related to your mental health, we must provide records mandated by state law. 

6. Your Rights Regarding Your PHI

Under HIPAA, you hold specific rights regarding the mental health records we maintain: 

• Right to Inspect and Copy: You have the right to look at or request a paper/electronic copy of your medical and billing records. (Note: This does not automatically include raw psychotherapy notes). We may charge a reasonable, cost-based fee for copies.

• Right to Request Restrictions: You can ask us to restrict how we use or share your PHI for treatment, payment, or operations. We are not required to agree to your request, unless you pay out-of-pocket in full for a service and ask us not to bill your insurance.

• Right to Confidential Communications: You can request that we contact you in a specific way (e.g., only calling your cell phone, or sending mail to a P.O. Box). We will accommodate all reasonable requests.

• Right to Amend Records: If you believe your records contain a mistake or missing information, you may submit a written request to amend them. We may deny this request, but we will explain why in writing within 60 days.

• Right to an Accounting of Disclosures: You have the right to request a list of the times we have shared your PHI for purposes other than treatment, payment, or operations over the past 6 years. 

7. Complaints and Changes to This Notice 

If you believe your privacy rights have been violated, you can file a formal, written complaint directly with our practice's Privacy Officer or with the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint. 

We reserve the right to change the terms of this notice. Any changes will apply to all PHI we already have, and the updated policy will be posted on our website and provided to you at your next session. 

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If you have questions about this Notice or your privacy rights, please contact:

Jennifer Pudlo Therapy
Jennifer Pudlo, Licensed Marriage and Family Therapist

CA- #90386
MI - #4101007479

IN  - #35002433A

Email: jenniferpudlolmft@gmail.com

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