Notice of Privacy Practices

Effective February 1, 2026

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

I am committed to protecting your personal health information. Protected health information (PHI) includes information that I, or my designees, have created or received regarding your health, health care, and payment for health care.

THIS NOTICE COVERS THE FOLLOWING ENTITIES PROVIDING CARE:

All administrative staff, employees, contract staff, supervisors or interns providing you care through my services and/or programs must abide by this Notice of Privacy Practices.

Pennsylvania law provides a higher level of protection for health care information and specifically limits the disclosure of certain types of PHI, including records regarding mental health, confirmed sexually transmitted disease, HIV/AIDS and drug and alcohol treatment. Information about this type of care can only be released in accordance with those stricter laws. Minors may consent to their own treatment for family planning services, sexually transmitted disease testing/treatment, outpatient mental health treatment or outpatient alcohol and drug abuse treatment.

PART 1 – YOUR RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION

Here is a listing of your rights with respect to your protected health information, along with a description of how you may exercise these rights:

  • You have a right to request limits on the way I disclose your health information. You must make the request in writing to my office and tell me what information you want to limit and to whom you want the limits to apply. I am not required to agree to the restriction.

  • You have the right to request how I provide confidential communications to you. For example, you may ask me to share information with you in a certain way or in a certain place. For example, you may ask me to send information to your work address instead of your home address; you may also request that I call you at work instead of at home. You must make this request in writing to my office. You do not have to explain the reason for your request. I am required to follow your request, if it is reasonable.

  • In most cases, you have the right to look at or get copies of the medical information that I have. You must make the request in writing to my office. I will respond to the request within 30 days. I may charge you a reasonable fee based on copying and other costs. In certain situations, I may deny your request and will tell you why I am denying it. In some cases, you may have the right to ask for a review of the denial.

  • You have a right to request a correction or an update of your records. You may ask me to amend or add missing information if you think there is a mistake. You must make the request in writing to my office and provide a reason for your request. In certain cases, I may deny the request. Such a denial will be given in writing. You may respond by filing a written statement of disagreement with me and ask that the statement be included in your PHI.

  • You have a right to get a list of persons or agencies to which my records were sent after April 14, 2003. You must make this request in writing to my office. The list will not include the releases of your information made for the purpose of treatment, payment, or health care operations. The list will not include information provided directly to you, or information that was sent with your written authorization.

  • You have a right to get a paper copy of the most recent version of this notice, if you request it.

  • You have the right to choose someone to act for you. If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

  • You have the right to withdraw the permission for me to release your information. If you sign an authorization for me to disclose information, you can revoke that authorization at any time. The revocation must be made in writing and given to my office. This will not affect information that has already been used or disclosed.

To exercise your rights under the law, call the numbers listed in this document or write my office. My staff or I will assist you with your request.

PART 2 – YOUR CHOICES

You have some choices in the way that I use and share your health information. Please let me know if you have a clear preference for how I share your information in the situations described below. In these cases, I will follow your preferences and instructions.

In these cases, you have both the right and choice to tell me to:

  • Share information with your family, close friends or others who are involved in your care or payment for your care

  • Share information in a disaster relief situation

  • Include your information in a hospital directory

If you are not able to tell me your preference, for example, if you are unconscious, I may share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, I will never share your information unless you give me written permission:

  • Marketing purposes

  • Sale of your information

  • Most sharing of psychotherapy notes

In the case of fundraising:

  • I may contact you for fundraising efforts, but you can tell me not to contact you again.

If I have your substance use disorder patient records, subject to 42 CFR Part 2, I will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.

PART 3 – MY RESPONSIBILITIES UNDER THE LAW

I am required by law to provide you with my Notice of Privacy Practices. This law is the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Under this law, I must protect the privacy of your “protected health information” or PHI. PHI is information that I have created or received regarding your health or payment for your health care. It includes both medical records and personal information, such as name, social security number, address, and phone numbers

I am required to:

  • Keep my protected health information private except as indicated below

  • Follow the terms of the Notice currently in effect

  • Give you this Notice

I reserve the right to change my practices regarding the protected health information I maintain. If I make changes, I will update my Notice and make it available to you. The most recent copy of the Notice will be posted in the office.

PART 4 – HOW I MAY USE OR DISCLOSE MEDICAL INFORMATION ABOUT YOU

I use and disclose PHI in a number of ways connected to your treatment, payment for your care, and health care operations. Here are some examples of how I may use or disclose your personal health information without your authorization.

To provide treatment; for example:

  • I may use medical information about you to provide you with emergency medical treatment or services.

  • I may disclose medical information about you to supervisors or psychiatrists with whom I consult to provide you with quality services.

To receive payment for services I provide or to obtain insurance authorization for services I recommend; for example:

  • If you have health insurance, I request payment from your health insurance plan for the services I provide. For example, I may need to give your health plan information about your planned visit to the insurance company so that your health plan will pay me for the visit.

  • I may also tell your health plan about my recommended treatment, preliminary diagnosis, and other information they may require to get their prior approval.

To carry out healthcare operations; for example:

  • I may use or disclose your health information in order to manage my programs and activities. For example, I may use your health information to review the quality of services you receive or to provide training to my staff.

  • I may use and disclose medical information to contact you by telephone or by mail as a reminder that you have/had an appointment.

As required by law I may use and disclose protected health information when required by federal or state law.

For judicial and administrative proceedings: I may disclose protected health information in response to an order of a court or administrative tribunal; in response to a subpoena, discovery request, or other lawful process.

For law enforcement purposes: I may disclose protected health information for to a law enforcement official.

For abuse reports and investigations: I may use and disclose information regarding suspected cases of abuse, neglect, or domestic violence, when the law so requires.

To respond to organ and tissue donation requests: I may use and disclose protected health information consistent with applicable laws in response to requests from organ procurement organizations.

To medical examiners/coroners or funeral directors: I may use and disclose protected health information consistent with applicable laws to allow them to carry out their duties.

To comply with workers’ compensation laws: I may disclose protected health information as authorized by laws relating to workers compensation or other programs that provide benefits for work-related injuries or illness without regard to fault.

For specialized government functions: I may use and disclose information to agencies administering programs that provide public benefits. For example, I may disclose information for the determination of Supplemental Security Income (SSI) benefits. I also may provide information to government officials for specifically identified government functions such as national security or military activities; or law enforcement custodial situations, such as correctional institutions.

To do research: I may use and disclose protected health information consistent with applicable laws in response to requests to complete health research.

To avoid serious threat to health or safety: I may use and disclose protected health information when we believe it necessary to avoid a serious threat to the health or safety of a person or the general public.

For public health and safety purposes as allowed or required by law: I may disclose protected health information to health care oversight agencies for oversight activities authorized by law.

Disaster relief: I may use and disclose information about you to assist in disaster relief efforts.

Use and disclosure of substance use disorder records subject to 42 CFR Part 2:

(A) If applicable, your substance use disorder ("SUD") records are protected by federal laws under 42 C.F.R. Part 2 ("Part 2"). This law provides extra confidentiality protections and requires a separate patient consent for the use and disclosure of SUD counseling notes. Each disclosure made with patient consent must include a copy of the consent or a clear explanation of the scope of the consent. It must also be accompanied by a written notice containing the language in 42 CFR Part 2.32(a). Disclosure of these records requires your explicit written consent, except in limited circumstances such as:

  • Medical Emergencies: to the extent necessary to treat you,

  • Reporting Crimes on Program Premises,

  • Child Abuse Reporting: In connection with incidents of suspected child abuse or neglect

    to appropriate state or local authorities, and

  • Fundraising: We will provide you with an opportunity to decline to receive any fundraising communications prior to making such communications.

You may revoke this consent at any time.

(B) Prohibitions on Use and Disclosure of Part 2 Records:

SUD records received from programs subject to Part 2, or testimony relaying the content of such records, shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless based on your written consent, or a court order after notice and an opportunity to be heard is provided to you or the holder of the record, as provided in Part 2. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested SUD record is used or disclosed. IF SUD records are disclosed to us or our business associates pursuant to your written consent for treatment, payment, and healthcare operations, we or our business associates may further use and disclose such health information without your written consent to the extent that the HIPAA regulations permit such uses and disclosure, consistent with the other provisions in this Notice regarding PHI.

OTHER USES AND DISCLOSURES REQUIRE MY WRITTEN AUTHORIZATION:

Uses and disclosures not described in this Notice will be made only as allowed by law or with your written authorization. You may revoke your authorization to me to disclose protected health information at any time; the revocation must be in writing. The revocation will not affect uses or disclosures that have already been made.

PART 5 – HOW YOU MAY ASK FOR HELP OR COMPLAIN

For More Information, please contact:

Privacy Office
Tessera Counseling and Wellness, LLC
9400 McKnight Road
Suite 201
Pittsburgh, PA 15237
Phone: 412-444-5062

If you believe your privacy rights have been violated, you may file a complaint with the Privacy Office at the address above. You may also complain to the Secretary of the U.S.

Department of Health and Human Services, at the address below. You will not be retaliated against for filing a complaint.

Office for Civil Rights
Medical Privacy, Complaint Division
U.S. Department of Health and Human Services
200 Independence Avenue, SW, HHH Building, Room 509H Washington, D.C. 20201
Phone: 866-627-7748
TTY: 886-788-4989
Email: www.hhs.gov/ocr