Notice of Privacy Practices

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.

The Mind Gym Counseling & Wellness Services (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

YOUR RIGHTS
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI.

• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

To amend PHI.

• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications (how PHI is sent to you).

• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared.

• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared.

• You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice.

• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To 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.

To file a complaint if you feel your rights are violated.

• You can file a complaint by contacting The Practice using the following information:

The Mind Gym Counseling & Wellness Services

8866 Commons Blvd

Suite 102

Twinsburg, OH 44087
Elizabeth Manzetti
440-715-5203

• 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/.
• The Practice will not retaliate against you for filing a complaint.

OUR USES AND DISCLOSURES
1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

• To treat you.
  • The Practice can use and share PHI with other professionals who are treating you. Disclosure for treatment purposes is not limited to the minimum necessary standard due to the need for complete information and/or the full record in order for you to receive quality care. "Treatment” includes but is not limited to: the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another.
    • Example: Your primary care doctor asks about your mental health treatment.
• To run the health care operations.
  • The Practice can use and share PHI to run the business, improve your care, and contact you.
    • Example: The Practice uses PHI to send you appointment reminders if you choose.
• To bill for your services.
  • The Practice can use and share PHI to bill and get payment from health plans or other entities.
    • Example: The Practice gives PHI to your health insurance plan so it will pay for your services.
• In response to a court order.
  • The Practice may disclose health information in response to a court or administrative order if you are involved in a lawsuit. The Practice may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

• To help with public health and safety issues
  • Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
  • Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
  • Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
  • Serious threat to health or safety: To prevent a serious and imminent threat to anyone's health or safety.
  • Abuse or Neglect: To report suspected abuse of a child, elder, or dependent adult.
• To comply with law, law enforcement, or other government requests
  • Required by law: If required by federal, state or local law.
  • Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request (The Practice prefers to obtain an Authorization from you before doing so).
  • Law enforcement: For law locate and identify you or disclose information about a victim of a crime, including reporting crimes occurring on The Practice's premises.
  • Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.
  • National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
  • Workers' Compensation: To comply with workers' compensation laws or support claims (The Practice prefers to obtain an Authorization from you before doing so).
• To comply with other requests
  • Coroners and Funeral Directors: To perform their legally authorized duties.
  • Organ Donation: For organ donation or transplantation.
  • Research: For research that has been approved by an institutional review board.
  • Inmates: The Practice created or received your PHI in the course of providing care.
  • Business Associates: To organizations that perform functions, activities or services on our behalf.

3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object
Unless you object, the Practice may disclose PHI:

• To your family, friends, or others if PHI directly relates to that person's involvement in your care.
• If it is in your best interest because you are unable to state your preference.

4. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:

• Psychotherapy Notes. The Practice keeps “psychotherapy notes”, as defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
  • For your treatment.
  • For The Practice's use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
  • For The Practice's and/or your practitioner's use in defending itself/herself in legal proceedings instituted by you.
  • For use by the Secretary of Health and Human Services to investigate The Practice's HIPAA compliance.
  • Required by law and the use or disclosure is limited to the requirements of such law.
  • Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
  • Required by a coroner who is performing duties authorized by law.
  • Required to help avert a serious threat to the health and safety of others.
• Marketing Purposes. The Practice will not use or disclose your PHI for marketing purposes.
• Sale of PHI. The Practice will not sell your PHI in the regular course of business.

You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.

OUR RESPONSIBILITIES

• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website themindgymcws.com.
• The Practice will inform you if PHI is compromised in a breach.

This Notice is effective on 3/27/25.