Notice of Privacy for Nancy Schornack, LMHC, CDWF - C

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law enacted to ensure the privacy and security of a consumers Protected Health Information (PHI).  PHI is individually identifiable health information that is transmitted or maintained in any form or medium.  Some examples of PHI include an individual’s name, social security number, address, and date of birth.

As your counselor I am required by law to protect the privacy of your mental health information.  I am also required to give you this notice which explains how I may disclose information about you to others when allowed by law.

The term “information” or “health information” in this notice includes any personal information that is created or received by a mental health care provider that relates to your mental health and/or that of your child(ren), the provision of mental health care to you, or the payment of such care.

I have the right to change my privacy practices.  If I do, I will provide you a revised notice within 60 days by direct mail or in person.


I must use and disclose your health information to provide information:

  • To you or someone who has the legal right to act for you
  • Where required by law

I have the right to use and disclose health information to operate my business.  For example I may use your health information:

  • For collection of payment of grossly overdue or delinquent accounts; account information may be disclosed to a billing collection agency.

I may use or disclose your health information for the following purposes under limited circumstances:

  • For appointment reminders.  I may use health information to contact you for appointment reminders using phone numbers and/or e-mail provided by you.
  • To persons involved with your care:  I may use or disclose your health information to a person involved in your care, such as a family member, when you are incapacitated or in an emergency or when permitted by law.
  • For reporting victims of abuse, neglect, domestic violence to government authorities, including a social service or protective service agency.
  • For judicial or administrative proceedings such as in response to a court order, search warrant, or subpoena.
  • For law enforcement purposes such as providing limited information to locate a missing person.
  • To avoid a serious threat to health or safety by, for example, disclosing information to public health agencies.

If none of the above reasons apply, then I must get your written authorization to use or disclose you and/or your child’s health information.  The dated Release of Information specifies what information may be disclosed, to whom, and during what period of time.  Your written authorization to disclose health information would apply in the following situations:

  • For payment of fees due me (whether by insurance or other third party payees such as churches) and to process claims for mental health care services.
  • For treatment information from other family members, referring physicians, other mental health counselors, or physicians to whom I may refer you.  This information may be shared via phone, consultation, in person, by fax or direct mail.
  • For specialized government functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
  • If a use or disclosure of health information is prohibited or materially limited by other applicable law, it is my intent to meet the requirements of the more stringent law.

To protect you health information records:

  • Information requested by referring or referred physicians or other mental health counselors may be shared in summary form form rather than in case note form when possible.
  • Appointment reminders will only be left with phone/fax numbers that are provided by you and with your permission.
  • Mental health records are stored on file applicable solely to you or your child’s counselor
  • Mental health records are stored in locked file cabinets when not in use.
  • After seven years of appointment inactivity, health information records are shredded or burned.


Federal and applicable state laws may require special privacy protections for highly confidential information about you.  “Highly confidential information” may include confidential information under Federal law governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

  1. HIV/AIDS;
  2. Mental health;
  3. Genetic testing;
  4. Alcohol and drug abuse;
  5. Sexually transmitted diseases and reproductive health information; and
  6. Child or adult abuse or neglect, including sexual assault.


The following are your rights with respect to your health information:

  • You have the right to ask to restrict uses or disclosures of your information for treatment, payment or health care operations.  You also have the right to ask to restrict disclosures to family members or to others involved in your health care or payment of your health care.  I may also have policies on dependent access that may authorize certain restrictions.  Please note that while I will try to honor your request and will permit requests consistent with my policies, I am not required to agree to any restriction.
  • You have the right to ask to receive confidential communications on information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).
  • You have the right to see and obtain a summary copy of health information that may be used to make decisions about you such as claims.
  • You have the right to a paper copy of this notice.  You may ask for a copy of this notice at any time.


If you have any questions about this notice or want to exercise any of your rights, please call me at 515-727-1667.

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