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HIPAA Privacy Notice


I. OUR PLEDGE REGARDING THE CONFIDENTIALITY OF HEALTH INFORMATION: Connections Wellness Group understands that health information about you and your health care is personal. We are committed to protecting health information about you. Your provider will need to create a record of the care and services you receive from Connections Wellness Group. This record provides you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which your provider may use and disclose health information about you. Below, a description of your rights to the health information kept about you and certain obligations your provider at Connections Wellness Group has regarding the use and disclosure of your health information. We are required by law to:

  • Make sure that protected health information (“PHI”) that identifies you is kept private.
  • Give you this notice of our legal duties and privacy practices with respect to health information.
  • Follow the terms of the notice that are currently in effect.
  • Inform you that Connections Wellness Group can change the terms of this notice, and such changes will apply to all information we have about you. The new notice will be available upon request, in the office, and on our website.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, an explanation will be provided along with some examples. Not every use or disclosure in a category will be listed. However, all of the ways your provider is permitted to use and disclose information will fall within one of the categories.

  • For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have a direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. Your provider may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in the diagnosis and treatment of your mental health condition.
  • Disclosures: Disclosures for treatment purposes are not limited to the minimum necessary standard. Therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, 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.
  • Lawsuits and Disputes: If you are involved in a lawsuit, your provider may disclose health information in response to a court or administrative order. Your provider may also disclose health information about your child in response to a subpoena, discovery request, or other lawful processes 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.


Psychotherapy Notes: Your Health Care Practitioner may keep “psychotherapy notes” as that term is 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 provider’s use in treating you.
  • For your provider’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 your provider’s use in defending themselves in legal proceedings instituted by you.
  • For use by the Secretary of Health and Human Services to investigate your provider’s compliance with HIPAA.
  • 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: As a psychotherapist and/or medical provider I will not use or disclose your PHI for marketing purposes.

Sale of PHI: As a psychotherapist, I will not sell your PHI in the regular course of my business.


Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:

  • When disclosure is required by state or federal law and the use or disclosure complies with and is limited to the relevant requirements of such law.
  • For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
  • For health oversight activities, including audits and investigations.
  • For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain an authorization from you before doing so.
  • For law enforcement purposes, including reporting crimes occurring in the office.
  • To coroners or medical examiners, when such individuals are performing duties authorized by law.
  • For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
  • Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
  • For workers’ compensation purposes. Although our preference is to obtain authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.
  • Appointment reminders and health-related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with your Health Care Practitioner. We may also use and disclose your PHI to tell you about treatment alternatives, policy changes, or other health care services or benefits that we off.


  • Disclosures to family, friends, or others: We may provide your PHI to a family member, friend, or another person that you indicate is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.


  • The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to request for the use or disclosure of certain PHI for treatment, payment, or health care operations purposes. Connections Wellness Group not required to agree to your request, and may say “no” if there is a potential to affect your health care.
  • The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full: You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
  • The Right to Choose How I Send PHI to You: You have the right to request for your provider to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and your provider will agree to all reasonable requests.
  • The Right to See and Get Copies of Your PHI: Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information as part of your record. Connections Wellness Group will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and Connections Wellness Group has the right to charge a reasonable, cost-based fee for doing so. You may find the fee schedule located in the financial intake forms.
  • The Right to Get a List of the Disclosures I Have Made: You have the right to request a list of instances in which your provider has disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided Connections Wellness Group with an Authorization. Your provider will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list will include disclosures made in the last six years unless you request a shorter time. This list will be provided to you at no charge, but if you make more than one request in the same year, Connections Wellness Group reserves the right to charge a reasonable cost-based fee for each additional request.
  • The Right to Correct or Update Your PHI: If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request for your provider to correct the existing information or add the missing information. Your provider may say “no” to your request but will respond to your request in writing within 60 days of receiving your request.
  • The Right to Get a Paper or Electronic Copy of this Notice: You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by email. And, even if you have agreed to receive this notice via email, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE: This notice will go into effect on the date signature is received.