NOTICE OF PRIVACY PRACTICES

Peaceful Life 30400 Detroit Rd #301 Westlake, Ohio 44145 | 440-605-6020 | peacefullifejodi@gmail.com

Effective Date: April 10, 2026

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

I. Our Legal Duty

Under federal law (HIPAA) and Ohio state law (Ohio Revised Code § 5122.31), Peaceful Life is required to protect the privacy of your Protected Health Information (PHI). PHI includes information that can be used to identify you and that relates to your past, present, or future physical or mental health conditions, the provision of healthcare to you, or payment for that care. We are required to provide you with this Notice about our privacy practices, our legal duties, and your rights concerning your PHI. We must follow the privacy practices described in this Notice. We are also required to notify you if there is a breach of your unsecured PHI.

II. How We Use and Disclose Your Information

We may use and disclose your PHI for the following routine purposes without your specific written authorization:

  • For Treatment: We may use your PHI to provide, coordinate, or manage your mental health therapy. For example, we may consult with your primary care physician or a psychiatrist to coordinate your overall care.

  • For Payment: We may use and disclose your PHI to bill and collect payment for the treatment and services provided to you. For example, we may share necessary information with your health insurance plan (such as Aetna, Anthem, Medicaid, Medicare, etc.) so they will pay for your sessions.

  • For Healthcare Operations: We may use your PHI for our internal business operations, such as quality assessment, training, audits, and administrative services.

III. Disclosures Required by Ohio and Federal Law (No Authorization Needed)

In certain situations, Ohio and Federal laws require or permit us to disclose your PHI without your consent. These include:

  • Duty to Warn / Protection from Harm: If we believe you present a clear, substantial, and imminent risk of serious harm to yourself or a specific, identifiable other person, we are legally required to take protective actions. This may include notifying emergency services, law enforcement, or the potential victim.

  • Abuse and Neglect Reporting: Under Ohio law, we are mandated reporters. We must report suspected abuse or neglect of a child, an elderly person, a developmentally disabled adult, or an animal to the appropriate authorities.

  • Court Orders and Subpoenas: We may disclose your PHI in response to a valid court order. If we receive a subpoena, we will attempt to obtain your written authorization or a protective order before releasing any mental health records.

  • Public Health and Safety: We may disclose PHI to authorized public health officials to prevent or control disease, injury, or disability.

  • Health Oversight Activities: We may disclose PHI to an agency overseeing the healthcare system, such as the Ohio Counselor, Social Worker, and Marriage and Family Therapist (CSWMFT) Board or Medicaid fraud investigators.

IV. Special Note on Minors in Ohio (ORC § 5122.04)

Because Peaceful Life treats children and adolescents, special Ohio laws apply:

  • Minors Age 14 and Older: Under Ohio Revised Code § 5122.04, a minor who is 14 years of age or older may consent to a limited amount of outpatient mental health services (up to 6 sessions or 30 days, whichever comes first) without the knowledge or consent of their parent or guardian. In these specific cases, the parent or guardian will not be informed of the treatment, will not have access to these records, and will not be billed, unless the minor consents to disclosure or there is a compelling, life-threatening emergency.

  • General Minors: For clients under 18 (outside of the exception above), parents/guardians generally have the right to access the minor's medical records. However, to maintain the therapeutic alliance, we often request that parents agree to keep the specific details of therapy sessions confidential, except in matters of safety.

V. Uses and Disclosures Requiring Your Written Authorization

  • Psychotherapy Notes: Peaceful Life keeps "psychotherapy notes" (personal notes kept separate from your official medical record). These are given special protection under HIPAA and require your explicit, separate written authorization to be disclosed to anyone, including your insurance company.

  • Marketing and Sale of PHI: We will never sell your PHI or use it for marketing purposes without your written authorization.

  • Other Uses: Any other uses and disclosures not described in this Notice will be made only with your written authorization. You may revoke this authorization in writing at any time.

VI. Your Rights Regarding Your PHI

You have the following rights regarding the PHI we maintain about you:

  • Right to Inspect and Copy: You have the right to look at and get a copy of your health information (with certain exceptions, such as psychotherapy notes). You must submit your request in writing. We may charge a reasonable fee for copying and mailing.

  • Right to Amend: If you believe your records are incorrect or incomplete, you may request an amendment in writing. We may deny your request if the information is accurate and complete, but we will provide you with a written explanation of the denial.

  • Right to an Accounting of Disclosures: You have the right to request a list of times we have shared your PHI for reasons other than treatment, payment, healthcare operations, or when you provided explicit authorization.

  • Right to Request Restrictions: You may ask us not to use or share certain PHI for treatment, payment, or operations. We are not required to agree to your request, except if you pay for a service out-of-pocket in full and request that we do not share that specific information with your health insurance plan.

  • Right to Confidential Communications: You have the right to request that we contact you in a specific way (e.g., only on your cell phone or only at a specific email address). We will agree to all reasonable requests.

  • Right to a Paper Copy: You have the right to receive a paper copy of this Notice at any time, even if you previously agreed to receive it electronically.

VII. Questions and Complaints

If you have questions about this Notice, disagree with a decision we make about access to your records, or believe your privacy rights have been violated, you may contact our Privacy Officer:

Privacy Officer: Jodi Walters | Phone: (440)-305-6020 | Address: 30400 Detroit Rd #301 Westlake, Ohio 44145

You also have the right to file a formal, written complaint with the Secretary of the U.S. Department of Health and Human Services. Peaceful Life will not retaliate against you in any way for filing a complaint.