Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES 

This notice describes how health information may be used and disclosed and how you can get access to this information. Please review it carefully. 

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. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you and describe certain obligations I have regarding the use and disclosure of your health information.  

My Responsibilities:  

I am required by law to: 

  • Maintain the privacy and security of your protected health information (“PHI”). 
  • Let you know promptly if a breach occurs that may have compromised the privacy or security of your information. 
  • Follow the duties and privacy practices described in this notice that is currently in effect and give you a copy of it. 
  • Not share your information other than as described in this notice unless you tell me I can in writing. You can change your mind at any time and notify us of this request in writing. 

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html 

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: 
The following categories describe different ways that I may use and disclose health information. For each category of uses or disclosures, I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories. 

  • For Treatment: 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. I may also disclose your protected health information for the treatment activities of any health care provider. This 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, to assist the clinician in diagnosis and treatment of your mental health condition. 

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information 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. 

  • Payment/Billing: I can use and share your health information to bill and get payment from health plans or other entities. Example: I give information about you to your health insurance plan so it will pay or reimburse for your services. 
  • Health Care Operations: I can use and share your health information to run my practice, improve your care, and contact you when necessary. Example: I use health information about you to manage your treatment and services. 
  • Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order or in response to a subpoena. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process 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. 
  • To the extent that I have your substance use disorder patient records, subject to 42 CFR part 2, I will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena. 

Redisclosure According to HIPAA 

When you consent to uses and disclosures for all future treatment and payment purposes and to run our business, I may share your information with other substance use disorder treatment programs, doctors’ offices, and health care businesses for those activities. If the person who receives it is subject to HIPAA, then they are allowed to use and share your information again without your consent for the purposes that HIPAA allows. Your information still cannot be used in legal proceedings against you unless (1) you consent or (2) based on a Part 2 court order and a subpoena (or similar legal requirement). 

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: 

In these cases, I never share your information unless you give me written permission: 

  1. Psychotherapy Notes. I do 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: 
    a. For my use in treating you. 
    b. For my 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 my use in defending myself in legal proceedings instituted by you. 
    d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. 
    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 or medical examiner who is performing duties authorized by law. 
    h. Required to help avert a serious threat to the health and safety of others. 
  1. Marketing Purposes    
  1. Sale of your PHI: As a counselor, I will never sell your PHI. 

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.  

I am allowed or required to share your information in other ways—usually in ways that contribute to the public good, such as public health and research. I must meet certain conditions in the law before I can share your information for these purposes. And in all cases, if I have substance use disorder patient records about you, subject to 42 CFR part 2, I cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena. Information disclosed under HIPAA may be subject to redisclosure by the recipient and therefore lose its protection. 

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

  1. 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, including the Department of Health and Human Services if it wants to see that I’m complying with federal privacy law. 
  1. For public health or safety issues, including reporting suspected child, elder, or dependent adult abuse, neglect, or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety. 
  1. For health oversight agencies for activities authorized by law, including audits and investigations. 
  1. For judicial and administrative proceedings, including responding to a court or administrative order or in response to a subpoena 
  1. For law enforcement purposes or with a law enforcement official, including reporting crimes occurring on my premises. 
  1. To coroners or medical examiners, when an individual dies and such individuals are performing duties authorized by law. 
  1. 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. 
  1. For special government functions, including military, national security, and presidential protective services 
  1. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI to comply with workers’ compensation laws. 
  1. For appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer. 

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT. 

For certain health information, you can tell me your choices about what I share. If you have a clear preference for how I share your information in the situations described below, please talk to me, and I will follow your instructions.  

In these cases, you have both the right and choice to tell me to: 

  1. Share 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, including serious or imminent threat to health or public safety. 
  1. Share information in a disaster relief situation 

If you cannot tell me your preference, for example if you are unconscious, I may share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety. 

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI: 

  1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care. 
  1. 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. 
  1. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send e-mail to a different address. I will agree to all reasonable requests. 
  1. The Right to See and Get Copies of Your PHI. You have the right to get a copy of your electronic medical record and other information that I have about you. I 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. I may charge a reasonable, cost-based fee for doing so. 
  1. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last seven years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request. 
  1. 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 that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 30 days of receiving your request. 
  1. The Right to Get a Paper or Electronic Copy of this Notice. At any time, you can ask for a paper copy of this notice, even if you have agreed to receive the notice electronically. 
  1. The Right to Choose Someone to Act For You. If someone has authority to act as your personal representative, such as if someone is your medical power of attorney or your legal guardian, that person can exercise your rights and make choices about your health information. I will make sure the person has this authority and can act for you before we take any action. 
  1. The Right to File a Complaint If You Feel Your Rights Are Violated. You can complain if you feel I have violated your rights by contacting me using the information listed on page 1. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html. I will not retaliate against you for filing a complaint. 

CHANGES TO THE TERMS OF THIS NOTICE 

I can change the terms of this notice and such changes will apply to all the information I have about you. The new notice will be available upon request, and I will send a copy electronically to you.  

Effective Date of This Notice: 02/16/2026  

Carla Kucinski, Owner, Space to Heal Counseling and Wellness, PLLC 

MS, LCMHCA, NCC 

Carla@spacetohealcounseling.com 

(336) 585-7188 

Acknowledgement of Receipt of Privacy Notice 

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 checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices. 

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