Notice of Privacy Practices

ELEVATE MENTAL HEALTH AND WELLNESS  ·  Effective Date: May 5, 2026

I. My Pledge Regarding Health Information

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide 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.

I am required by law to:

• Make sure that protected health information ("PHI") that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.

I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. How I May Use and Disclose Health Information About You

For Treatment, Payment, or Health Care Operations: Federal privacy rules 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 written authorization, to carry out treatment, payment or health care operations. For example, if I were to consult with another licensed health care provider about your condition, I would be permitted to use and disclose your personal health information to assist in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard because health care providers need access to the full record to provide quality care. "Treatment" includes the coordination and management of health care providers with a third party, consultations between providers, and referrals.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order, subpoena, discovery request, or other lawful process, but only if efforts have been made to notify you about the request or to obtain a protective order.

III. Certain Uses and Disclosures Require Your Authorization

Psychotherapy Notes. I keep "psychotherapy notes" as defined in 45 CFR § 164.501. Any use or disclosure of such notes requires your authorization unless the use or disclosure is:

• For my use in treating you.
• For training or supervising mental health practitioners.
• For my use in defending myself in legal proceedings instituted by you.
• For use by the Secretary of Health and Human Services to investigate HIPAA compliance.
• Required by law, limited to the requirements of such law.
• Required for certain health oversight activities.
• Required by a coroner performing duties authorized by law.
• Required to help avert a serious threat to the health and safety of others.

Marketing Purposes. I will not use or disclose your PHI for marketing purposes.

Sale of PHI. I will not sell your PHI in the regular course of my business.

IV. Certain Uses and Disclosures Do Not Require Your Authorization

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

• When disclosure is required by state or federal law.
• For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing 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.
• For law enforcement purposes, including reporting crimes occurring on my premises.
• To coroners or medical examiners performing duties authorized by law.
• For research purposes.
• Specialized government functions, including military missions, intelligence operations, and correctional institution safety.
• For workers' compensation purposes.
• Appointment reminders and health-related benefits or services.

V. Certain Uses and Disclosures Require You to Have the Opportunity to Object

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other 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.

VI. Your Rights With Respect to Your PHI

• The Right to Request Limits on Uses and Disclosures. You may ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree if I believe it would affect your health care.
• The Right to Request Restrictions for Out-of-Pocket Expenses. You have the right to request restrictions on disclosures to health plans if the PHI pertains solely to a service you have paid for out-of-pocket in full.
• The Right to Choose How I Send PHI to You. You may ask me to contact you in a specific way or to send mail to a different address, and I will agree to all reasonable requests.
• The Right to See and Get Copies of Your PHI. You have the right to get an electronic or paper copy of your medical record within 30 days of a written request. A reasonable, cost-based fee may apply.
• The Right to Get a List of Disclosures. You may request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or operations. I will respond within 60 days. The list covers the last six years.
• The Right to Correct or Update Your PHI. If you believe there is a mistake or missing information in your PHI, you may request a correction. I may say "no" but will tell you why in writing within 60 days.
• The Right to Get a Paper or Electronic Copy of This Notice. You may request a paper or email copy of this Notice at any time.