PHI is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical health or condition, treatment, or payment for health care services and includes information that we have created or received regarding your health or payment for your health. It also includes both your medical records and personal information such as your name, social security number, address, and phone number.

I. OUR PLEDGE REGARDING HEALTH INFORMATION: We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We 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 we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. Under federal law, we are required to:

● Protect the privacy of your PHI. All of our employees and clinicians are required to maintain the confidentiality of PHI and receive appropriate privacy training
● Provide you with this Notice of Privacy Practices explaining our duties and practices regarding your PHI
● Follow the practices and procedures set forth in the Notice
● We can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are 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. We 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 because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality 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, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.


1. Psychotherapy Notes. We do sometimes 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 our use in treating you. b. For our 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 our use in defending

ourselves in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate our 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 mental health practice, we will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a mental health practice, we 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, we 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 our 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 research purposes, including studying and comparing the mental health of patients
who received one form of therapy/treatment versus those who received another form of
therapy/treatment for the same condition.
Specialized government functions, including, ensuring the proper execution of military
missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’ compensation purposes. Although our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.
Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.


1. Disclosures to family, friends, or others. We 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.


The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we 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 We Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we 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 we have about you. We 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 we may charge a reasonable, cost-based fee for doing so as permitted by state law.
The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or healthcare operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we 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 we correct the existing information or add the missing information. We may say “no” to your request, but we 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.




Telehealth is the delivery of psychiatric and other mental health and medical services using interactive audio and visual electronic systems where the clinician and the patient are not in the same physical location. Ruby Mental Wellness allows its clinicians to perform telehealth when clinically appropriate using HIPAA-compliant platforms including Zoom. The interactive electronic systems used by these platforms incorporate network and software security protocols to protect the confidentiality of patient information and audio/visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

Potential Telepsychiatry Benefits:

– Increased accessibility to care

-Patient convenience

-Obtaining expertise of a distant clinician

Potential Telepsychiatry Risks:

-Information transmitted may not be sufficient (e.g., poor resolution of video) to allow for appropriate medical decision-making by my clinician.

-Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment. -Security protocols can fail, causing a breach of privacy of my confidential medical information.

-In rare cases, a lack of access to all the information that might be available in a face-to-face visit, but not in a telehealth session, could result in the omission of care involving other health problems or possible adverse drug interactions.

If I decide that the benefits outweigh the risks, I may request telehealth sessions when I schedule follow-up appointments. If my clinician agrees, I will be scheduled for a telehealth session, and I will be sent an internet link with instructions to log into the “waiting room” immediately prior to my scheduled appointment.

My Rights:

(1) I understand that all laws protecting the privacy and confidentiality of medical information also apply to telehealth.

(2) I understand that all the state rules and regulations which apply to in-person sessions also apply to telehealth sessions

(3) I understand that my clinician has the right to withhold or withdraw their consent for the use of telehealth at any time during the course of my care.

(4) I understand that I have the right to withhold or withdraw my consent for the use of telehealth at any time during the course of my care, and withdrawal of my consent will not affect any future care or treatment from my clinician unless it becomes logistically impossible to continue care. Referrals will be made if that is the case.

My Responsibilities:

(1) I will inform my clinician as soon as my session begins of my physical location and will not unexpectedly join from states where my clinician is not licensed. I understand the clinician may need to terminate the session should I join from a location where they are not licensed. Exceptions are made in the case of emergency/crisis or sporadic visits while traveling that are clinically necessary for appropriate continuity of care. I will also join from a safe and private location and not while driving or operating heavy machinery.

(2) I will ensure the proper configuration and functioning of all my electronic equipment prior to my session because the computer, tablet, or mobile telephone I use must have a working camera and audio input so that my clinician can see and hear me in real time.

(3) I will not record any telepsychiatry sessions without written consent from Ruby Mental Wellness, and I understand that my clinician will not record any of our telehealth sessions without my written consent.

(4) I will inform my clinician as soon as my session begins if any other person can hear or see any part of our session.

(5) If I lose my connection during a session, I will immediately attempt to log back into the Zoom “waiting room.” (6) If the audio I am receiving during a telehealth session is not complete and

clear, I will attempt to let my clinician know or contact Ruby Mental Wellness at 615-200-7674, to schedule a new appointment or for further instructions. I understand that it is my responsibility to ensure that all equipment is in working order, and is subject to the 10-minute grace period outlined above.

behalf: __________________________________