Samara Counseling Services, LLC
10521 W. Forest Home Ave., Suite 301
Milwaukee, WI 53228
(414) 293-2493

Effective Date: April 1, 2024

This notice explains how your health information may be used and disclosed and how you can access that information. Please review it carefully.

At Samara Counseling, protecting your privacy is a core part of providing ethical mental health care. Federal law requires that I maintain the privacy of your protected health information (PHI) and provide you with this Notice of Privacy Practices.

Your health information may be used or disclosed in the following ways.

Your information may be used to provide therapy and coordinate your care. This may include consulting with other licensed health professionals involved in your treatment or referring you to another provider.

If you use insurance benefits, your health information may be shared with your insurance provider to obtain payment for services.

Information may be used for activities necessary to operate the practice, such as clinical consultation, supervision, training, quality improvement, or administrative tasks.

In certain circumstances, federal or state law allows or requires disclosure of protected health information without your written permission. These situations may include:

• When disclosure is required by law
• Reporting suspected child abuse, elder abuse, or abuse of a vulnerable adult
• Preventing a serious threat to health or safety
• Health oversight activities such as audits or investigations
• Judicial or administrative proceedings (such as court orders)
• Law enforcement requests permitted by law
• Workers’ compensation claims
• Requests from coroners or medical examiners
• Certain government functions such as military or national security activities

Whenever possible, I will make reasonable efforts to limit disclosures to the minimum necessary information.

Psychotherapy notes receive special protection under HIPAA. These notes are kept separate from the rest of your clinical record.

Your written authorization is required before psychotherapy notes may be disclosed, except in limited circumstances allowed by law, such as:

• Use for your treatment
• Clinical supervision or training
• Legal defense if a claim is brought by you
• Compliance investigations by the U.S. Department of Health and Human Services
• Situations required by law or necessary to prevent serious harm
• 
  

Your contact information may be used to:

• Send appointment reminders
• Contact you about scheduling
• Inform you about services offered by this practice
• 
  

Your written authorization is required before your health information can be used or disclosed for:

• Marketing purposes
• The sale of protected health information
• Any other use not described in this notice

You may revoke your authorization at any time in writing.

With your permission, your health information may be shared with a family member, friend, or other person involved in your care or payment for services.

You may object to these disclosures at any time.

You have several rights regarding your protected health information.

You have the right to review or obtain a copy of your clinical record, except for psychotherapy notes. Requests must be made in writing, and records are typically provided within 30 days.

A reasonable fee may apply for copies.

If you believe information in your record is incorrect or incomplete, you may request that it be corrected. If a request is denied, you will receive a written explanation.

You may request limits on how your information is used or disclosed. While requests will be considered, I am not required to agree if the restriction could affect your care.

If you pay for a service out of pocket in full, you may request that information related to that service not be shared with your insurance provider.

You may request that I contact you in a specific way or at a specific location. Reasonable requests will be accommodated.

You may request a list of certain disclosures of your health information made within the past six years.

You may request a paper or electronic copy of this notice at any time.

As a health care provider, I am required to:

• Maintain the privacy and security of your protected health information
• Provide you with this notice of privacy practices
• Follow the terms of the notice currently in effect
• Notify you if a breach occurs that may have compromised your information

This notice may be updated periodically. Updated versions will be available in the office and on the practice website.

If you believe your privacy rights have been violated, you may file a complaint with Samara Counseling or with the U.S. Department of Health and Human Services.

Filing a complaint will not affect the care you receive.

Samara Counseling Services, LLC
10521 W Forest Home Ave., Suite 301
Milwaukee, WI 53228
(414) 293-2493

You may also file a complaint with:

U.S. Department of Health and Human Services
Office for Civil Rights
https://www.hhs.gov/ocr/privacy/hipaa/complaints/

Clients receiving services from Samara Counseling will be asked to acknowledge receipt of this Notice of Privacy Practices as part of the intake process.