HIPAA Notice of Privacy Practices

MICHELLE WAKELEY LICSW LLC 

Doing Business As (DBA) AWAKEN MENTAL WELLNESS

726 E. Park Ave. #185

Fairmont, WV 26554

(304) 534-9321

info@awakenmentalwellness.com

EFFECTIVE DATE: August 05, 2026

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, through the client portal, and on my website at www.awakenmentalwellness.com.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Disclosures for treatment purposes are not subject to the HIPAA 'minimum necessary' standard because treating providers may need access to the complete clinical record in order to provide appropriate care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. 

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

• Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
  a. For my use in treating you.
  b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
  c. For my use in defending myself in legal proceedings instituted by you.
  d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
  e. Required by law and the use or disclosure is limited to the requirements of such law.
  f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
  g. Required by a coroner who is performing duties authorized by law.
  h. Required to help avert a serious threat to the health and safety of others.

• Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

• Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

• When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

• For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

• For health oversight activities, including audits and investigations.

• For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

• For law enforcement purposes, including reporting crimes occurring on my premises.

• To coroners or medical examiners, when such individuals are performing duties authorized by law.

• For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.

• Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

• Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

• The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

• The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

• The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

• The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

• The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

• The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

• The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

VII. POLICY REGARDING BREACHES OF CONFIDENTIALITY

Whereas all good faith efforts will be made to protect your confidential information, it is necessary to plan for potential breaches. Whether due to human error or bad actors, if there is reason to believe an impermissible use or disclosure of protected health information has occurred there will be an immediate evaluation, including assessment of the type of information, with whom, whether it has been viewed, and the impact of the potential breach. If it is determined that a breach may occur without additional action, risk mitigation steps will be implemented to prevent imminent or further loss, theft, or mishandling of PHI. If it is determined a breach has happened, (1) Clients will be informed by phone or in writing without unreasonable delay, within 60 days of the discovery. If the breach involves out-of-date or inaccurate contact information, there will be a notification posted on the homepage of the website for at least 90 days. That notification will include a toll-free number clients can call for assistance in determining whether their data was involved in the breach. (2) The Department of Health and Human Services will be notified of the breach. For breaches impacting fewer than 500 clients, HHS will be notified within the first 60 days of the next calendar year. For breaches impacting more than 500 clients, HHS will be notified within 60 days of the discovery of the breach. (3) For breaches impacting more than 500 clients, a media source that services the client area will also be notified about the nature and extent of the breach to ensure any clients who do not receive the individual notice are informed.

VIII. Complaints

If you believe your privacy rights have been violated, you may file a complaint with Michelle Wakeley LICSW LLC d/b/a Awaken Mental Wellness or with the U.S. Department of Health and Human Services, Office for Civil Rights. Filing a complaint will not affect your access to treatment or result in retaliation.

Acknowledgement of Receipt of Notice of Privacy Practices

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. 

By signing below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices, and that you have been given ample opportunity to ask questions and that any questions have been answered to your satisfaction.

Client’s Name: 

Client’s Date of Birth: 

Client’s Signature:  

Today’s Date: 

IF THE CLIENT HAD ASSISTANCE REVIEWING AND COMPLETING THIS FORM, PLEASE INCLUDE:

Name of Person Assisting Client: 

Relationship to the Client: 

Phone Number for Person Assisting Client: 

Signature of Person Assisting Client: