I am required by the Health Insurance Portability & Accountability Act of 1996 (HIPAA) to provide confidentiality for all medical/mental health records and other individually identifiable health information in my possession. This Notice is to inform you of the uses and disclosures of confidential information that may be made by Just Mind, and of your individual rights and Just Mind's legal duties with respect to confidential information.


HIPAA gives you rights and power as to how your information is shared. Below are the most common uses of HIPAA:

Ways in which I may use and disclose your protected Health information:

I may use and disclose at my discretion your medical records for each of the following purposes only: treatment, payment and health care operations.

I may contact you to provide appointment reminders or other services that may be of interest to you. I will disclose your protected health information to any person you identify that is involved in payment for your care.

I will use and disclose your protected health information when required by federal, state or local law. There are certain situations in which as a therapist I am required by ethical standards to reveal information obtained during therapy to persons or agencies  even if you do not give permission. These situations are as follows:

(a) If you threaten grave bodily harm or death to yourself or another person, I am required by ethical standards to inform the intended victim and/or appropriate law enforcement agencies;

(b) if you report to me your knowledge of physical or sexual abuse of a minor child or of an elder (over 65) or any sexual conduct/contact with a minor, I am required by law to inform the appropriate child welfare or social agency which may then investigate the matter;

(c) if I am required by a court of law (court order) to turn over records to the court or if I am ordered to testify regarding those records.

Any other uses and disclosures will be made only with your written authorization. You will be provided with an authorization form upon request. A separate form will be needed for each request for release of information. The authorization for release of records is valid until it expires or is revoked. You may revoke authorization in writing a I am required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

Notification of breaches

In the case of a breach, Just Mind requires to notify each affected individual whose unsecured PHI has been compromised. Even if such a breach was caused by a business associate, Just Mind is ultimately responsible for providing the notification directly or via the business associate.  If the breach involves more than 500 persons, OCR must be notified in accordance with instructions posted on its website. Just Mind bears the ultimate burden of proof to demonstrate that all notifications were given or that the impermissible use or disclosure of PHI did not constitute a breach and must maintain supporting documentation, including documentation pertaining to the risk assessment.

How to complain about privacy practices

If you have any questions about this notice or any complaints about my privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me at: William Schroeder, 512-843-7665 x2.

Please sign to indicate you understand my operation use of your information for treatment, payment and health care operations as stated above.

____________________________                        _____________________
Signature                                                Date

____________________________                        _____________________
Signature - (if more than one person)                Date