Notice of Privacy Practices
Effective date: [DATE] | Last updated: [DATE]
Breeze Mental Health
Dublin Office: 5626 Franz Road, Dublin, OH 43017
Dallas Office: 3154 Memorial Highway, Suite 100, Dallas, PA 18612
Mildred Office: 7406 PA Route 487, Suite 10, Mildred, PA 18632
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
1. Our pledge regarding your health information
Breeze Mental Health is required by law to maintain the privacy and security of your protected health information (PHI). We are required to follow the privacy practices described in this notice, provide you with a copy of it, and promptly notify you if a breach occurs that may have compromised the privacy or security of your information.
2. Your rights
When it comes to your health information, you have specific rights under HIPAA:
Get an electronic or paper copy of your medical record: You can ask to see or get a copy of your health and claims records. We will provide a copy or a summary within 30 days of your request and may charge a reasonable, cost-based fee.
Ask us to correct your medical record: You can ask us in writing to correct health information that you think is incorrect or incomplete. We may deny your request with a written explanation within 60 days.
Request confidential communications: You can ask us to contact you in a specific way (such as home or office phone) or send mail to a different address. We will accommodate all reasonable requests.
Ask us to limit what we share: You can ask us not to use or share certain health information for treatment, payment, or operations. We are not required to agree if it affects your care, but if you pay out-of-pocket in full, we must agree not to share that information with your health plan.
Get a list of those with whom we’ve shared information: You can request an accounting of disclosures made during the six years prior to your request date (excluding treatment, payment, healthcare operations, and authorized disclosures). One list per 12-month period is free; additional requests may carry a reasonable, cost-based fee.
Get a paper copy of this notice: You are entitled to a paper copy of this notice at any time upon request, even if you agreed to receive it electronically.
Choose someone to act for you: A medical power of attorney or legal guardian may exercise your privacy rights once their legal authority is verified.
File a complaint: You can file a complaint if you feel your rights have been violated by contacting our office or the U.S. Department of Health and Human Services (HHS) Office for Civil Rights. We will not retaliate against you for filing a complaint.
3. Your choices
For certain health information, you can tell us your preferences on how we share it:
With your permission or direction: You may instruct us to share information with family members, close friends, or others involved in your care or payment, as well as during disaster relief efforts. If you are unable to express a preference (e.g., unconscious), we may share information if determined to be in your best interest or to reduce an imminent threat.
Written authorization required: We will never market your services, sell your information, or share psychotherapy notes without your prior written permission.
Fundraising: If we contact you for fundraising efforts, you have the right to opt out of future communications.
4. How we use and disclose your health information
We typically use and disclose your health information in the following ways:
Treatment: We use your health information and share it with healthcare professionals involved in treating you (e.g., coordinating with a doctor or specialist).
Healthcare operations: We use and disclose information to operate the practice, improve clinical quality, and contact you when necessary.
Billing and payment: We share your health information to bill and collect payment from health plans or other responsible entities.
5. Other permitted and required disclosures
We are permitted or required to share your information without authorization in specific scenarios that serve the public good:
Public health and safety: Preventing disease, reporting adverse medication reactions, handling product recalls, reporting suspected abuse or neglect, and mitigating serious threats to health or safety.
Legal and government compliance: Complying with state or federal laws, including HHS compliance audits.
Specialized functions: Responding to organ donation requests, working with coroners or medical examiners, addressing workers’ compensation claims, and fulfilling lawful law enforcement or national security requests.
Lawsuits and legal actions: Responding to administrative orders, court orders, or subpoenas.
6. Substance use disorder records (42 CFR Part 2)
To the extent that we maintain substance use disorder patient records subject to 42 CFR Part 2, we will not share that information for civil, criminal, administrative, or legislative investigations or proceedings against you without either (1) your written consent or (2) a specific court order and subpoena.
7. Additional practice policies
Outpatient status: Breeze Mental Health operates strictly as an outpatient clinic and does not maintain a hospital directory.
Psychotherapy notes: Notes documenting counseling sessions that are maintained separately may be excluded from the general right of record access.
Practice policies: Disclosures may also be handled in accordance with the Practice Policies agreement signed during intake.
8. Changes to this notice
We reserve the right to change the terms of this notice. Revised terms will apply to all health information we maintain. The updated notice will be available on our website and upon request in our offices.
9. Contact and privacy inquiries
If you have questions, wish to exercise your privacy rights, or need to file a complaint, please contact our Privacy Officer:
Contact Person: Privacy Officer Sarah Red
Mailing Address: PO BOX 1703, Powell, OH 43065
Phone: 570-539-7234
You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:
