HIPAA Notice of Privacy

Our Pledge Regarding Your Health Information

 

Ampersand Counseling & Well-Being, PLLC (“we,” “us,” or “our”) is committed to protecting the privacy of your health information. We create a record of the care and services you receive to provide quality care and comply with legal requirements. This notice applies to all records of your care that we maintain, whether created by our clinicians or others.

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We are required by law to maintain the privacy of your Protected Health Information (PHI), provide you with this notice of our legal duties and privacy practices, and notify you following a breach of the privacy or security of your unsecured PHI.

 

We are required to abide by the terms of this notice currently in effect. We reserve the right to change this notice and make the new notice provisions effective for all information we already have, as well as any information we receive in the future.

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Who Will Follow This Notice

 

This notice applies to all clinicians, staff, and workforce members of Ampersand Counseling & Well-Being, PLLC who may have access to your health information, including:

• Lauren Bergiel, CMHCI, PCC

• Paige Crawford

• Monica Isaac

• Kaitlyn Bowie

• All administrative and support staff

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How We May Use and Disclose Your Health Information

 

The following categories describe how we may use and disclose your PHI. For each category, we provide an example. Not every use or disclosure in a category will be listed.

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For Treatment

We may use your PHI to provide, coordinate, or manage your therapy and related services. For example, your therapist may share information with another clinician within our practice to ensure coordinated care. We may also disclose your PHI to other health care providers involved in your care with your authorization.

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For Payment

We may use and disclose your PHI to obtain payment for services. For example, we may share information with your health insurance plan to verify coverage or obtain approval for treatment.

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For Health Care Operations

We may use and disclose your PHI for internal operations, including quality assessment, staff training, business management, and compliance activities. For example, we may review your record to evaluate the quality of care provided by our clinicians.

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Uses and Disclosures Requiring Your Written Authorization

Psychotherapy Notes. Psychotherapy notes are notes recorded by a mental health professional documenting or analyzing the contents of a conversation during a counseling session, kept separate from the general medical record. Under HIPAA, psychotherapy notes receive special protection. We must obtain your written authorization for most uses and disclosures of psychotherapy notes, with limited exceptions, including use by the originating therapist for treatment, use for training, or to defend a legal action.

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Marketing and Sale of PHI. We will not use or disclose your PHI for marketing purposes or sell your PHI without your written authorization.

You may revoke your authorization at any time in writing, except to the extent we have already taken action in reliance on the authorization.

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Uses and Disclosures Without Authorization

We may use or disclose your PHI without your authorization for the following purposes, subject to applicable legal requirements:

• As Required by Law: When required by federal, state, or local law.

• Public Health Activities: To report information to public health authorities for activities such as disease prevention, injury reporting, and abuse or neglect reporting .

• Health Oversight Activities: To agencies that oversee the healthcare system, for audits, investigations, and licensure .

• Judicial and Administrative Proceedings: In response to a court order, subpoena, or other lawful process .

• Law Enforcement: For purposes such as reporting crimes, identifying suspects, or responding to legal process.

• To Avert a Serious Threat: When necessary to prevent or lessen a serious and imminent threat to the health or safety of you or others .

• Coroners, Medical Examiners, and Funeral Directors: As necessary to carry out their duties.

• Organ and Tissue Donation: To organizations involved in procurement.

• Research: Under certain conditions with approval by an institutional review board.

• Specialized Government Functions: For military, national security, or correctional purposes.

• Workers' Compensation: As necessary to comply with workers' compensation laws.

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Illinois State Law Considerations

Illinois has specific laws regarding mental health confidentiality that may provide greater protection than HIPAA. Under the Illinois Mental Health and Developmental Disabilities Confidentiality Act (MHDDCA), mental health records cannot be disclosed without your written consent or a court order, except in limited circumstances such as obtaining insurance benefits, coordination of services between state agencies, protection from serious harm, or disclosure in legal proceedings where your mental condition is at issue.

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Where Illinois law is more restrictive than HIPAA, we will follow the more protective law.

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Your Rights Regarding Your Health Information

You have the following rights concerning your PHI:

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Right to Inspect and Copy

You have the right to inspect and obtain a copy of your PHI maintained in our designated record set. This includes mental health and billing records. You may request an electronic copy if your record is maintained electronically. We may deny your request in limited circumstances, and you may appeal certain denials.

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Right to Request an Amendment

If you believe information in your record is incorrect or incomplete, you may request in writing that we amend it. We may deny your request if the information was not created by us, is not part of the record you are permitted to access, or is accurate and complete.

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Right to an Accounting of Disclosures

You have the right to request a list of certain disclosures of your PHI made by us, other than for treatment, payment, health care operations, or with your authorization. Your request must be in writing and specify a time period (not to exceed six years) .

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Right to Request Restrictions

You have the right to request that we restrict uses or disclosures of your PHI for treatment, payment, or health care operations. We are not required to agree to your request, except in certain circumstances. We must agree to restrict disclosure to a health plan if you pay in full, out of pocket, for the service and request the restriction.

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Right to Request Confidential Communications

You have the right to request that we communicate with you about your health information by alternative means or at an alternative location. Your request must be in writing and specify how and where you wish to be contacted.

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Right to a Paper Copy of This Notice

You have the right to a paper copy of this notice upon request, even if you have received it electronically.

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Our Legal Duties

We are required by law to maintain the privacy of your PHI, provide you with notice of our legal duties and privacy practices, and abide by the terms of the notice currently in effect. We will not use or disclose your PHI other than as described in this notice without your written authorization.

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We will notify you following a breach of the privacy or security of your unsecured PHI.

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Changes to This Notice

We reserve the right to change this notice at any time. Changes will apply to information we already have about you, as well as information we receive in the future. If we make a material change to this notice, we will post the revised notice on our website at [insert website URL] and make it available at our office. The revised notice will include a new effective date.

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Complaints

If you believe your privacy rights have been violated, you may file a complaint with:

Ampersand Counseling & Well-Being, PLLC
Attn: Privacy Officer
5225 Old Orchard Rd STE 24B
Skokie, IL 60077
847-868-2132

 

You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services:
Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240

Chicago, IL 60601

Toll-Free Phone: 1-800-368-1019
Website: www.hhs.gov/ocr/privacy/hipaa/complaints

 

We will not retaliate against you for filing a complaint.

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Contact Information

For questions about this notice or our privacy practices, please contact:

Ampersand Counseling & Well-Being, PLLC
Attn: Privacy Officer
5225 Old Orchard Rd STE 24B
Skokie, IL 60077
847-868-2132
info@ampersandpractice.com

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Effective Date

This Notice of Privacy Practices is effective as of September 13, 2026.