SUMMARY
Mental Health Group Practice
Effective Date: February 16, 2026
THIS NOTICE EXPLAINS HOW YOUR HEALTH INFORMATION MAY BE USED AND HOW YOU CAN ACCESS IT. PLEASE REVIEW CAREFULLY.
Our Commitment to Your Privacy
Your health information is private. We are required by federal law (HIPAA and 42 CFR Part 2) to:
Protect your Protected Health Information (PHI)
Provide this notice explaining our privacy practice
Follow the terms of this notice
Notify you if a data breach occurs
How We May Use and Share Your Information
We may use or share your information without written permission for:
Treatment
To provide and coordinate your mental health care (including consultation within our group practice or with other providers involved in your care).
Payment
To bill insurance companies or other responsible parties.
Health Care Operations
For quality improvement, supervision, training, licensing, and business management.
When Required by Law
Including court orders, public health reporting, suspected abuse reporting, law enforcement, or preventing serious harm.
Special Protection for Substance Use Disorder (SUD) Records
Some substance use disorder treatment records are protected by federal law (42 CFR Part 2) and have extra confidentiality protection.
If these protections apply:
We generally must obtain your written consent before sharing those records.
These records cannot be used in legal proceedings against you without your written consent or a specific court order.
Redisclosure Notice:
Information shared under HIPAA may be redisclosed by others and may no longer be protected. However, substance use disorder records protected by 42 CFR Part 2 cannot be redisclosed without your written permission unless allowed by law.
Uses That Require Your Written Permission
We will obtain your written authorization for:
Use or disclosure of psychotherapy notes (with limited exceptions)
Marketing (we do not use your information for marketing)
Sale of PHI (we do not sell your information)
You may revoke authorization in writing at any time.
Your Rights
You have the right to:
Get a copy of your records (except psychotherapy notes)
Request corrections to your records
Request limits on certain uses or disclosures
Request confidential communication (for example, at a different address)
Receive a list of certain disclosures we have made
Receive a paper or electronic copy of this notice
Questions or Complaints
If you have questions or believe your privacy rights were violated, contact:
Privacy Officer: Nancy Pohlman – Brave Spaces
Phone/Email: nancy@brave-spaces.org
You may also file a complaint with the U.S. Department of Health and Human Services at:
www.hhs.gov/ocr/privacy/hipaa/complaints
You will not be penalized for filing a complaint.
Acknowledgment of Receipt
BY CLICKING ON THE SUBMIT BUTTON BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.