Notice of Privacy Practices
Mindful Behaviors . . . with Johnna Pilipchuk, MA, LPA
Notice of Privacy Practices
This practice follows professional standards and laws to protect your privacy. Federal laws require me to provide
you with a notice of my privacy practices.
This notice describes how your individual identifiable information may be used or disclosed. Also, this notice
describes how you may get access to your individual identifiable information that is maintained by this practice.
Please read this notice and ask me any questions you have on how I keep your information confidential.
Ways I Can Use and Disclose Information WITHOUT Your Permission
Typically, I will ask for your written permission or authorization to share or obtain information with others.
However, I may use and disclose information about you without your authorization in the following circumstances:
- TREATMENT: I may use your information and disclose it to manage or coordinate treatment provided to
you. For example, I may share information with another therapist or your physician to coordinate services.
- PAYMENT: I may use and disclose necessary information about you to obtain payment for my services.
For example, this information could include information that your health insurance plan may require before
it approves or pays for treatment services I recommend for you.
- HEALTH CARE OPERATIONS: I may need to use or disclose information for my practice activities.
Examples of these activities include:
- Quality assessment to see how well I’m doing in serving individuals, couples and families.
- Clinical supervision to meet state licensure and/or certification requirements.
- Education and training of students or other professionals.
- Compliance activities to ensure I am properly following policies, procedures, laws, regulations, and
I may use or disclose information about you in several other circumstances in which you do not have an
opportunity to agree or object. These situations include:
- REQUIRED BY LAW: I may need to disclose information for judicial or other administrative proceedings.
For example, I may need to disclose information in response to a court order.
- ABUSE OR NEGLECT: I am required to disclose information if I believe that you or a family member
have been a victim of abuse or neglect OR if you or a family member is abusing or neglecting another
- DANGER TO SELF OR OTHERS: I am required to take steps to prevent you harming yourself or
- LAW ENFORCEMENT: Law enforcement purposes may include:
5. PUBLIC HEALTH: I may be required by law to report health related information for public health activities.
- Legal processes required by law
- Limited information requests for identification and location purposes
- pertaining to victims of a crime
- in the event that a crime occurs on my premises
6. OTHER CIRCUMSTANCES: Although not typically encountered in my practice, there are other situations
when I may disclose information without your written permission.
Examples of these circumstances include providing information for research, information on inmates or military
veterans, and national security activities.
For any reason other than those listed above, I will ask for your written authorization before I use or disclose
information about you. Also, any authorization can be canceled any time in writing. (If you tell me you are
canceling an authorization, I will have you sign a request during the current or next visit.) If canceled, I will no
longer disclose information that was allowed under that specific authorization.
Your Rights About Your Private Identifiable Information
- Request Restrictions: You may request further restrictions on my uses and disclosures of your
information. I may not be able to agree to all requested restrictions. Please let me know if you want
specific restrictions on your information.
- Different Ways to Communicate: Typically I will communicate by mailing or phoning your residence.
However, you may prefer a different way for me to contact you. For example, you may ask me to contact
you at a specific address or phone. Please note that cell phones and e-mail may not offer confidentiality or
- Right to See and Copy Information: You may see and receive copies of your information maintained in
your designated record. I may charge for copying your designated record. There are situations in which I
do not have to comply with your request. However, I will say in writing if I cannot comply with a request.
- Right to Request Amendment of Your Information: You may request that information about you be
amended or changed. I may deny your request if I did not create the information (it was obtained from
another source). Also, I may deny your request if I believe the information is correct. Denials will be
written and will describe your rights for further review. If I agree to amend, I will make reasonable efforts
to share with any person who may have received your information that it needs amending. Please ask me if
you want to amend your information that I maintain in your designated record.
- Listing of Disclosures Made: You may request a list of certain disclosures of your information for up to
the last six (6) years. This list does not include disclosures made prior to April 14, 2003 (when the Federal
Privacy Rule took effect) or disclosures related to your treatment, payment or our practice operations, and
those disclosures required by law. Ask me if you desire a listing of disclosures.
- Copy of the notice: You may request a copy of this notice at any time. A copy is available at my
- You may File a Complaint About My Privacy Practice: If you think I have violated your privacy rights
described in this notice, or you want to complain to me about my privacy practices you can talk to me
about this. Also, you may send a written complaint to the secretary, Department of Health and Human
If you send a complaint, I will not take any action against you or change my treatment of you in any way.