HIPPA Notice of Privacy Practices

Lives Transforming Counseling’s HIPPA Notice of Privacy Practices to Protect the Privacy of Your Health Information


This HIPAA Notice of Privacy Practices (the “Notice“) contains important information regarding your medical information. Our current Notice is posted at [ELECTRONIC LOCATION]. You also have the right to receive a paper copy of this Notice and may ask us to give you a copy of this Notice at any time. If you received this Notice electronically, you are entitled to a paper copy of this Notice. If you have any questions about this Notice please contact the person listed below.

The Health Insurance Portability and Accountability Act of 1996 (“HIPAA“) imposes numerous requirements on health care providers regarding how certain individually identifiable health information – known as protected health information or PHI – may be used and disclosed. This Notice describes how Lives Transforming Counseling (“LTC”) may use and disclose your protected health information for treatment, payment, or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights to access and control your protected health information. “Protected health information” is information that is maintained or transmitted by LTC, which may identify you and that relates to your past, present, or future physical or mental health or condition and related mental health services.

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you and will use it to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request of it. This Notice applies to all of the medical records we maintain.

We are required by law to abide by the terms of this Notice to:

  • Make sure that medical information that identifies you is kept private.
  • Give you this Notice of our legal duties and privacy practices with respect to medical information about you.
  • Follow the terms of the Notice that is currently in effect.

I. How We May Use and Disclose Medical Information about You.

HIPAA generally permits use and disclosure of your health information without your permission for purposes of health care treatment, payment activities, and health care operations. These uses and disclosures are more fully described below. Please note that this Notice does not list every use or disclosure; instead, it gives examples of the most common uses and disclosures.

  • Treatment: When and as appropriate, we may use or disclose medical information to facilitate medical treatment or services by providers. We may disclose medical information to health care providers, including doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you. For example, we might disclose medical information in consult with another health care provider who is treating you, such as your family physician or another mental health provider.
  • Payment: When and as appropriate, we may use and disclose medical information to obtain reimbursement and facilitate payment for the treatment and services you receive from us. For example, we may share medical information with your health insurance provider to assist with determining your eligibility or coverage and to coordinate reimbursement and payment for the treatment and services you receive from us.
  • Health Care Operations: When and as appropriate, we may use and disclose medical information for activities that relate to the performance and operations of LTC. For example, we may use medical information in connection with quality assessment and improvement activities; business-related matters such as audits, administrative services, and legal services; and case management and care coordination.

We will always try to ensure that the medical information used or disclosed is limited to a “Designated Record Set” and to the “Minimum Necessary” standard, including a “limited data set,” as defined in HIPAA and American Recovery and Reinvestment Act of 2009 (“ARRA”) for these purposes. We may also contact you to provide information about treatment options or alternatives or other health-related benefits and services that may be of interest to you.

II. Other Permitted Uses and Disclosures Requiring Authorization

We may use or disclose medical information for purposes outside of treatment, payment, health care operations, or those circumstances listed in Part III below when your appropriate authorization and consent is obtained. In those instances when we are asked for information for purposes outside of treatment, payment, health care operations, or those circumstances listed in Part III below, we will obtain an authorization from you before releasing this information.

We will also need to obtain an authorization or consent from you before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes that your counselor has made about your conversation during a private, group, joint, or family counseling session, which your counselor has kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. However, your Psychotherapy Notes may be used without your authorization or consent by the originator of the Psychotherapy Notes for treatment or by us to defend ourselves in a legal action or other proceeding brought by you.

You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage. The law provides the insurer the right to contest the claim under the policy.

III. Permitted Uses and Disclosures that Do Not Require Consent or Authorization

Pursuant to Indiana law, we are restricted in the ways that we can use and disclose your mental health records without your authorization. However, we may use or disclose your mental health records without your consent or authorization in the following circumstances as provided for in Ind. Code § 16-39-2-6:


  • If the disclosure is made to you (unless it is determined by a physician that the release would be detrimental to your health);
  • Disclosures to our employees in certain circumstances;
  • For payment purposes;
  • For data collection, research, and monitoring managed care providers if the disclosure is made to the division of mental health;
  • For law enforcement purposes or to avert a serious threat to the health and safety of you or others;
  • To a coroner or medical examiner;
  • To satisfy reporting requirements including in cases where we believe or have reason to believe that a child is a victim of child abuse or neglect or a crime or that an endangered adult  has been harmed or threatened with harm as a result of abuse or neglect, a crime, or exploitation of their personal services or property;
  • To satisfy release of information requirements that are required by law such as laws related to worker’s compensation;
  • To another provider in an emergency;
  • For legitimate business purposes;
  • Under a court order including in a proceeding to determine mental competency, or a proceeding in which a defense of mental competency is raised. Absent a court order, we will not release your mental health records without the written authorization of you or your legally appointed representative as such information is privileged under Indiana law;
  • To the Secret Service if necessary to protect a person under Secret Service protection; or
  • To the statewide waiver ombudsman.

IV. Patient’s Rights

You have the following rights regarding medical information that we maintain about you:

  • Right to Request Restrictions: You have the right to request a restriction on certain uses and disclosures of your medical information for treatment, payment, healthcare operations, or to persons involved in your care, except when specifically authorized by you, when required by law, or in the case of an emergency. However, we are not legally required to agree to your request. We will inform you of our decision on your request. Additionally, you have the right to restrict disclosures of your medical information to your health plan for payment and health care operations purposes (and not for treatment) if the disclosure pertains to a health care item or service for which you paid out of pocket in full.
  • Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request that we communicate with you about medical matters in a confidential manner, such as sending you mail to an address other than your home address, by notifying us in writing of the specific manner or location for us to communicate with you. We will not ask you the reason for you request and we will make a good faith effort to honor your request. However, we are not legally required to approve your request if the request is unreasonable or infeasible. We will inform you of our decision on your request.
  • Right to Inspect and Copy: In most cases, you have the right to inspect and obtain an electronic or paper copy of medical information that we use to make decisions about your care. If you submit a written request for copies, we may charge a fee for the cost of copying, mailing, or other related supplies and services. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision. On your written request, we will discuss with you the details of the request and denial process.
  • Right to Amend: If you believe that information in your record is incorrect or if important information is missing, you have the right to request an amendment of your information by submitting a request in writing that provides the reason for requesting the amendment. We may deny your request for amendment if the information was not created by us, if it is not part of the record maintained by us, or if we determine that the record is accurate. On your written request, we will discuss with you the details of the amendment process.
  • Right to an Accounting: You generally have the right to receive an accounting of those instances where we have disclosed your medical information where such disclosures were required by law or made in connection with public health activities. You do not have a right to an accounting of disclosures where such disclosures were made for treatment, payment, or health care operations or where you specifically authorized a disclosure. When requesting an accounting of disclosures, you must state the time period desired for the accounting, which may not be longer than six years and may not include dates before April 14, 2003, and your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. On your written request, we will discuss with you the details of the accounting process.
  • Right to a Paper Copy: You have the right to obtain a paper copy of the Notice from us upon request, even if you have agreed to receive the notice electronically.


1. Breach Notification.

Pursuant to changes to HIPAA required by the Health Information Technology for Economic and Clinical Health Act of 2009 and its implementing regulations (collectively, “HITECH Act”) under the ARRA, this Notice also reflects federal breach notification requirements in the event that your “unsecured” protected health information (as defined under the HITECH Act) is acquired by an unauthorized party.

We understand that medical information about you and your health is personal and we are committed to protecting your medical information. Furthermore, we will notify you following the discovery of any “breach” of your unsecured protected health information as defined in the HITECH Act (the “Notice of Breach”). Your Notice of Breach will be in writing and provided via first-class mail, or alternatively, by email if you have previously agreed to receive such notices electronically. Your Notice of Breach shall be provided without unreasonable delay and in no case later than 60 days following the discovery of a breach and shall include, to the extent possible:

  • A description of the breach.
  • A description of the types of information that were involved in the breach.
  • The steps you should take to protect yourself from potential harm
  • A brief description of what we are doing to investigate the breach, mitigate the harm, and prevent further breaches.
  • Our relevant contact information.

Additionally, for any substitute Notice of Breach provided via web posting or major print or broadcast media, the Notice of Breach shall include a toll-free number for you to contact us to determine if your protected health information was involved in the breach.

VI. Changes to this Notice

We can change the terms of this Notice at any time. If we do, the new terms and policies will be effective for all of the medical information we already have about you as well as any information we receive in the future. In the event we change our notice, we will post the new notice in the office and on our website. We will provide you a copy of the new notice upon your request.

VII. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Lisa Pay, LCSW and/or send a written complaint to the Indiana Professional Licensing Agency or the Indiana Attorney General’s Office.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

VIII. Effective Date

This notice will go into effect on 12/01/20.