Notice of Privacy Practices

This Notice describes how your health information may be used and disclosed, and how you can access this information. Please review it carefully.

I. Our Commitment to Your Privacy

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with specific legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice explains how we may use and disclose health information about you. We also describe your rights to the health information we maintain about you, as well as our specific obligations 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.
  • Provide you with this notice regarding my legal duties and privacy practices related to health information.
  • Follow the terms of the notice that is currently in effect.

We reserve the right to modify the terms of this Notice at any time. Any changes will apply to all information we have about you. If updates are made, we will provide you with a new copy of the Notice and document the update in your client file. The most current version will also be available upon request and on our website.

II. How We May Use and Disclose Your Information

We may use and disclose your PHI for the following purposes without your written authorization:

Treatment, Payment, and Health Care Operations: We may use your PHI to coordinate care, bill insurance, and manage practice operations. For example, our mental health therapists may consult with another healthcare provider about your care.

Legal and Administrative Requests: We may disclose your PHI in response to a court order, subpoena, or other lawful process.

III. Uses and Disclosures Requiring Authorization

  1. If psychotherapy notes are kept as defined by HIPAA, their use and disclosure is further restricted as follows:
    a. For our use in treating you.
    b. For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
    c. For our use in defending ourselves in legal proceedings instituted by you.
    d. For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA  (the Health Insurance Portability and Accountability Act, a federal law that protects the privacy and security of your health information).
    e. Required by law, and the use or disclosure is limited to the requirements of such law.
    f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
    g. Required by a coroner who is performing duties authorized by law.
    h. Required to help avert a serious threat to the health and safety of others.
  2. Marketing Purposes. As mental health therapists, we will not use or disclose your protected health information (PHI) for marketing purposes.
  3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. Uses and Disclosures That Do Not Require Authorization

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

  1. When disclosure is required by state or federal law, the use or disclosure complies with and is limited to the relevant requirements of such law.
  2. Where state law provides additional privacy protections beyond HIPAA, we will follow the more stringent law.
  3. 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.
  4. For health oversight activities, including audits and investigations.
  5. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
  6. For law enforcement purposes, including reporting crimes occurring on our premises.
  7. To coroners or medical examiners, when such individuals are performing duties authorized by law.
  8. 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.
  9. Specialized government functions, including ensuring the proper execution of military missions, protecting the President of the United States, conducting intelligence or counter-intelligence operations, or helping to ensure the safety of those working within or housed in correctional institutions.
  10. For workers’ compensation purposes. Although my preference is to obtain authorization from you, we may disclose your PHI in order to comply with workers’ compensation laws.
  11. Appointment reminders and health-related benefits or services. We may use and disclose your protected health information (PHI) to contact you to remind you of an upcoming appointment with us.

V. Disclosures to Family and Caregivers

We 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 emergencies. You may withhold or revoke this consent at any time.

VI. Your Rights Regarding Your PHI

  1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us not to use or disclose certain protected health information (PHI) for treatment, payment, or healthcare operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care.
  2. 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.
  3. The Right to Choose How We Send PHI to You. You have the right to request that we contact you in a specific manner (for example, home or office phone) or to send mail to a different address, and we will comply with all reasonable requests.
  4. 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 that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary.

    Requests must be submitted in writing. We will respond within the timeframes required by law.
  1. The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will provide will include disclosures made in the last six years, unless you request a shorter time frame. We will give the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost-based fee for each additional request.
  2. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.

VII. Acknowledgment of Receipt

Under HIPAA, you have the right to receive this Notice of Privacy Practices. By signing or electronically acknowledging your intake documents, you confirm that you have been offered or received a copy of this Notice.

VIII Complaints or Concerns About Privacy

If you have any concerns or believe your privacy rights have been violated, please contact me directly. I am committed to addressing your concerns promptly and respectfully.

Contact: Alexandra Coker, LPC

Breakaway Counseling & Consulting LLC

‪4539 N 22nd St # 5178, Phoenix, AZ 85016

(602) 456-2846 

alexandra@breakawayaz.com

You also have the right to file a complaint with the U.S. Department of Health and Human Services. No retaliation will occur for filing a complaint. Learn more at: www.hhs.gov/ocr/privacy/hipaa/complaints

Effective Date of this Notice

This notice went into effect on 09/05/2025

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By agreeing to this form, you are acknowledging that you have received a copy of the HIPAA Notice of Privacy Practices.

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