Notice of Privacy Practices

 I. Uses and Disclosures for Treatment, Payment, and Heath Care Operations 

Synergy Therapy and Counseling LLC may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written consent. To help clarify these terms, here are some definitions: 

•  “PHI” refers to information in your health record that could identify you. 

•  “Treatment, Payment and Health Care Operations”  

  • Treatment is when Synergy Therapy and Counseling LLC  provides, coordinates or manages your health care and other services related to your health care. An example of treatment includes when Synergy Therapy and Counseling LLC consults with another health care provider, such as your family physician or another psychologist.  

  • Payment is when Synergy Therapy and Counseling LLC obtains reimbursement for your healthcare.  

  • Health Care Operations are activities that relate to the performance and operation of my practice. Examples of healthcare operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

• “Uses” applies only to activities within the Synergy Therapy and Counseling LLC office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.  

• “Disclosure” applies to activities outside of the Synergy Therapy and Counseling LLC office, such as releasing, transferring, or providing access to information about you to other parties.

 II. Uses and Disclosures Requiring Authorization

Synergy Therapy and Counseling LLC may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when Synergy Therapy and Counseling LLC is asked for information for purposes outside of treatment, payment and health care operations, Synergy Therapy and Counseling LLC will obtain an authorization from you before releasing this information. “Psychotherapy notes” are notes your therapist has made during a conversation which could include a private, group, joint, or family counseling session (or telephone conversations pertinent to any counseling session), which your therapist have kept separate from the rest of your clinical record. These notes are given a greater degree of protection than PHI. 

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) Synergy Therapy and Counseling LLC have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.  

 

III. Uses and Disclosures with Neither Consent nor Authorization 

Synergy Therapy and Counseling LLC may use or disclose PHI without your consent or authorization in the following circumstances:  

• Child Abuse: reasonable cause to believe that a child has been abused, Synergy Therapy and Counseling LLC and contracted therapists must report that belief, as required by law, to the appropriate authorities.

•  Adult and Domestic Abuse: reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, Synergy Therapy and Counseling LLC and contracted therapists must report that belief, as required by law, to the appropriate authorities.  

• Health Oversight Activities: If a governmental agency, such as the Indiana Attorney General’s Office, is conducting an investigation into Synergy Therapy and Counseling LLC or an individual contracted therapist of Synergy Therapy and Counseling LLC, then  Synergy Therapy and Counseling LLC is required to disclose PHI upon receipt of a subpoena.  

• Judicial and Administrative Proceedings: If the patient is involved in a court proceeding and a request is made for information about the professional services provided you and/or the record thereof, such information is privileged under state law, and Synergy Therapy and Counseling LLC will not release information without the written authorization of you (or your legally appointed representative) or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.  

• Serious Threat to Health or Safety: If determined, or pursuant to the standards of the profession should determine, that you present a clear and immediate probability of physical harm to yourself, to other individual(s), or to society, Synergy Therapy and Counseling LLC and/or contracted therapists of Synergy Therapy and Counseling LLC may communicate relevant information concerning this to the potential victim, appropriate family member, medical or law enforcement personnel, or other appropriate authorities.  

• Worker’s Compensation: If you file a worker’s compensation claim, Synergy Therapy and Counseling LLC may be required to disclose PHI, such as your diagnosis and treatment records, to relevant parties or officials. Synergy Therapy and Counseling LLC may disclose PHI regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law that provide benefits for work-related injuries or illness without regard to fault. 

• Further uses permitted under HIPAA: case management, care coordination, quality assessment and improvement activities, accreditation and licensing, staff training, and fraud and abuse detection

IV. Patient’s Rights and Therapist‘s Duties 

Patient’s Rights:  

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of PHI. However, Synergy Therapy and Counseling LLC  is not required to agree to a restriction you request.

• Right to Receive Confidential Communications by Alternative Means and Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know you are seeing someone for counseling. Upon your request, Synergy Therapy and Counseling LLC will send correspondence to another address.)  

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in your mental health and billing records used to make decisions about you as long as the PHI is maintained in the clinical record. We will respond to your written request within 15 calendar days of receipt. If we require additional time, we will notify you in writing of the reason for the delay and the expected completion date. You may inspect your records in person and may take notes or photographs of your information. We will provide a written estimate of any fees before fulfilling your request. Synergy Therapy and Counseling LLC may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, a representative of Synergy Therapy and Counseling LLC, such as your therapist, will discuss with you the details of the request and denial process.  

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Synergy Therapy and Counseling LLC may deny your request. On your request, a representative of Synergy Therapy and Counseling LLC, such as your therapist,  will discuss with you the details of the amendment process.  

• Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request,  your therapist will discuss with you the details of the accounting process.

•  Right to a Paper Copy – You will be provided a paper copy of this notice from Synergy Therapy and Counseling LLC and will be asked to acknowledge receipt of this notice. 

Therapist’s Duties:  

• Synergy Therapy and Counseling LLC and all contracted therapists are  required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. 

• Synergy Therapy and Counseling LLC reserves the right to change the privacy policies and practices described in this notice. Unless Synergy Therapy and Counseling LLC notifies you of such changes, however,  Synergy Therapy and Counseling LLC is required to abide by the terms currently in effect.  

• If Synergy Therapy and Counseling LLC revises policies and procedures, your therapist will provide you with a written copy of those revisions at the next appointment or by mail.

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 V. Complaints 

If you are concerned that your therapist has violated your privacy rights, or you disagree with a decision made about access to your clinical records, you may contact the administrative office at the above phone and/or address. 

You may also send a written complaint to the Indiana State Department of Health and the Secretary of the U.S. Department of Health and Human Services. Synergy Therapy and Counseling LLC can provide you with the appropriate addresses upon request. 

You have specific rights under the Privacy Rule. Synergy Therapy and Counseling LLC  will take no retaliatory action against you for exercising your right to file a complaint. 

VI. Effective Date, Restrictions and Changes to Privacy Policy 

The Notice, pursuant to the Health Insurance Portability and Accountability Act (HIPAA), has been in effect since April 14, 2003. Synergy Therapy and Counseling LLC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that Synergy Therapy and Counseling LLC or it’s contracted therapists maintain. Synergy Therapy and Counseling LLC will provide you with a revised notice in person or by mail

VII. Special Protections for Behavioral Health and Substance Use Disorder Records (Effective February 16, 2026)

Synergy Therapy and Counseling  provides mental health and substance use disorder treatment services. Records related to substance use disorder diagnosis, treatment, or referral for treatment are protected by federal law under 42 C.F.R. Part 2, in addition to HIPAA.

We may use and disclose your substance use disorder records for treatment, payment, and health care operations as permitted by law. However, in most cases, we will obtain your written authorization before disclosing these records.

Federal law prohibits recipients of substance use disorder treatment records from further using or disclosing this information unless expressly permitted by your written consent or as otherwise allowed by law.

Violations of these protections may be reported to the U.S. Department of Health and Human Services.

Redisclosure Notice (Required for SUD Records)

NOTICE TO RECIPIENT: Federal law prohibits the recipient of substance use disorder treatment records from using or disclosing this information unless expressly permitted by the patient’s written consent or as otherwise permitted by law.