Notice of Privacy Practices

Ariel Mantzoor, LCSW, P.A. 561-320-2709

Effective Date: 10/31/25

Acknowledgment 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 (“PHI”).

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 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 the information I have about you. The new Notice will be available upon request, in my office, and on my website.

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.

1. For Treatment, Payment, or Health Care Operations

Federal privacy rules allow health care providers with a direct treatment relationship with the patient/client to use or disclose the patient/client’s PHI without written authorization, to carry out treatment, payment, or health care operations.

I may also disclose your PHI for the treatment activities of any health care provider. For example, if a clinician consults with another licensed health care provider about your condition, we may use and disclose PHI to assist in diagnosis and treatment.

I may also use your PHI for operations purposes, including sending appointment reminders, billing invoices, and other documentation.

Disclosures for treatment purposes are not limited to the minimum necessary standard because therapists need access to full information to provide quality care.

The word “treatment” includes coordination and management of health care providers, consultations, and referrals.

2. Lawsuits and Disputes

If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about you or your minor child(ren) in response to a subpoena, discovery request, or other lawful process, but only if efforts have been made to notify you or obtain a protective order.

III. Certain Uses and Disclosures Require Your Authorization

1. Psychotherapy Notes

I keep “psychotherapy notes” as defined in 45 CFR § 164.501. Any use or disclosure requires your Authorization unless the use is:

  • For my use in treating you.

  • For my use in training or supervising mental health practitioners.

  • For my use in defending myself in legal proceedings instituted by you.

  • For use by the Secretary of HHS to investigate HIPAA compliance.

  • Required by law or for certain health oversight activities.

  • Required by a coroner or to avert a serious threat to health or safety.

2. Marketing Purposes

I will not use or disclose your PHI for marketing without your written consent. This includes reviews posted publicly that contain PHI; a HIPAA authorization will be requested. Consent can be withdrawn at any time via written request.

3. Sale of PHI

I will not sell your PHI.

IV. Uses and Disclosures That Do Not Require Your Authorization

I may use and disclose PHI without your Authorization for:

  1. Appointment reminders and health-related services.

  2. Required disclosures by state or federal law.

  3. Public health activities, including reporting abuse or threats.

  4. Health oversight activities, audits, or investigations.

  5. Judicial and administrative proceedings.

  6. Law enforcement purposes.

  7. Coroners or medical examiners.

  8. Research purposes.

  9. Specialized government functions.

  10. Workers’ compensation compliance.

  11. Organ and tissue donation requests.

V. Certain Uses and Disclosures Require You to Have the Opportunity to Object

Disclosures to family, friends, or others involved in your care may occur with your consent. In emergencies, consent may be obtained retroactively to mitigate serious threats.

VI. Your Rights with Respect to Your PHI

  1. Request Limits on Uses and Disclosures – You may ask me not to use or disclose certain PHI; I may deny if it affects care.

  2. Request Restrictions for Out-of-Pocket Expenses Paid in Full – You may restrict disclosure to health plans for fully paid services.

  3. Choose How I Send PHI – You may request communication by specific methods or addresses.

  4. See and Get Copies of PHI – Electronic or paper copy within 30 days of written request; cost-based fee may apply.

  5. Get a List of Disclosures – Accounting of disclosures within the last six years; first list free per year.

  6. Correct or Update PHI – Request corrections or additions; I may deny but must respond in 60 days.

  7. Get a Paper or Electronic Copy of this Notice – You may request a paper copy anytime.

  8. Choose Someone to Act for You – Medical power of attorney or legal guardian may act on your behalf.

  9. Revoke Authorization – You may revoke any prior authorization.

  10. Opt out of Communications and Fundraising – You may opt out.

  11. File a Complaint – Contact me or the HHS Office for Civil Rights; no retaliation.

VII. Changes to this Notice

I may change the terms of this Notice, which will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.