Notice of Privacy Practices

The Mind Pillow Counseling Marie C. Wallace, LPCC Effective October 3, 2026

Privacy questions and complaints: Marie C. Wallace Phone: (502) 501-4500 Email: marie@themindpillowcounseling.com

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

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 The Mind Pillow Counseling, including my separate psychotherapy notes where applicable. 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.

- Notify you following a breach of unsecured protected health information when notification is required by law.

- Use or disclose information not otherwise described in this notice only with your written authorization, unless otherwise permitted or required by law. You may revoke an authorization in writing at any time, except to the extent I have already acted in reliance on it.

- 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, in my office, and on my website.

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: Subject to the additional state-law protections described below, HIPAA permits certain uses and disclosures of health information for treatment, payment, and health care operations without a separate written authorization. I will obtain informed written consent or authorization whenever applicable law requires it. I may also disclose your protected health information for the treatment activities of any health care provider. This is subject to applicable consent, confidentiality, and privilege requirements. For example, if a clinician were to consult with another licensed health care provider about your condition, information may be shared as permitted by applicable law and any required consent to assist in diagnosis and treatment.

Payment: I may use or disclose information to bill for services and receive payment, subject to applicable consent requirements. For example, an insurance claim may include your diagnosis and the service provided. Health care operations: I may use information to manage my practice and improve care. For example, I may review records to evaluate documentation quality.

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, I may disclose health information in response to a court or administrative order. A subpoena or other request does not automatically authorize release of your counseling records. I will review applicable confidentiality and privilege requirements before responding and obtain your authorization when required. Any disclosure must meet applicable legal conditions, including notice or protective-order requirements where applicable.

Additional protections for counseling records

I serve clients in Kentucky, Ohio, and South Carolina. The disclosure categories in this notice do not override more protective applicable laws. Counseling communications may be privileged, and I will assert or protect that privilege when required.

In Kentucky, counselor-client privilege generally protects confidential counseling communications in legal proceedings, subject to exceptions in Kentucky Rule of Evidence 506. In Ohio, I will obtain informed written consent before revealing confidential information unless an applicable exception permits or requires disclosure, including a legal reporting duty or a clear and present danger to you or others. In South Carolina, counseling communications and treatment records are confidential and privileged subject to applicable state and federal exceptions. I will apply any additional protection that governs your records.

Certain uses and disclosures require your authorization

1. 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. Permitted by law to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

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

3. Sale of PHI. I do not sell your protected health information.

Information disclosed to a recipient may be disclosed again and may no longer be protected by HIPAA, although other laws may still protect it. If I ever receive substance-use disorder records protected by 42 CFR Part 2, I will apply those additional protections. Such records or testimony about them cannot be used in proceedings against you without the required written consent or a qualifying court order accompanied by a subpoena or other legal mandate.

Other uses and disclosures not described in this notice require your written authorization unless otherwise permitted or required by law. To revoke an authorization, send me a written request using the privacy contact information above. Revocation does not undo disclosures already made in reliance on your authorization.

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:

1. 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.

2. 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.

3. For health oversight activities, including audits and investigations.

4. 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.

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

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

7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. 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.

10. 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.

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.

You have the following rights with respect to your PHI

1. 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.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. If you or someone other than your health plan pays for a service in full out of pocket, you can request that I not disclose information about that service to your health plan for payment or health care operations. I must honor that request unless disclosure is required by law. Please tell me before information is submitted to your health plan.

3. 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.

4. 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.

5. 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 that are subject to the accounting requirement. This generally excludes disclosures for treatment, payment, health care operations, disclosures you authorized, and other exceptions allowed by law. 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.

6. 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.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to 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.

8. The Right to a Personal Representative. A person legally authorized to act for you may exercise your privacy rights within the scope of that authority. I will verify the person's authority and apply any legal exceptions before sharing information.

9. The Right to File a Complaint. If you believe your privacy rights have been violated, you may complain to Marie C. Wallace using the phone number or email above. You may also complain directly to the U.S. Department of Health and Human Services Office for Civil Rights at https://www.hhs.gov/hipaa/filing-a-complaint/index.html or by writing to 200 Independence Avenue SW, Washington, DC 20201. You do not need to complain to me first. I will not retaliate against you for filing a complaint.

Effective date of this notice

This notice went into effect on October 3, 2026

Acknowledgement of Receipt of Privacy Notice

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. Signing an acknowledgment confirms receipt of this notice; it is not an authorization to disclose your information.