Effective October 5, 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.
This Notice describes how Mindset Studio, LLC may use and disclose your protected health information (PHI) and explains your rights regarding that information. Federal law requires us to give you this Notice and to follow the terms of the Notice currently in effect.
1. Our legal duties
Mindset Studio, LLC is required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other applicable laws to maintain the privacy and security of your PHI, to give you this Notice of our legal duties and privacy practices, to notify you if a breach of your unsecured PHI occurs, and to follow the terms of the Notice currently in effect.
2. How we may use and disclose your information
Treatment. We may use and share your health information to provide, coordinate, and manage your care. For example, we may consult with your physician or psychiatrist about your treatment.
Payment. We may use and share your health information to bill and collect payment for services. For example, we may prepare a superbill you submit to your health plan.
Healthcare operations. We may use and share your health information to run the practice, for example for quality review, clinical supervision or consultation, training, and practice management.
Appointment reminders. We may contact you to remind you of appointments or to share information about your care, using the contact method you choose.
Business associates. We work with vendors who perform services for us, such as our electronic health record and telehealth platform and our billing services. They may receive PHI only to do that work, and they must sign a written agreement to protect it.
3. Disclosures we may make without your authorization
Federal law, and the law of the state where you are located when you receive services (Wisconsin or Ohio), allow or require us to share PHI without your written authorization in the limited situations below. We share only what the law permits and only what is needed.
- Required by law. When federal, state, or local law requires it, including mandatory reporting of suspected abuse or neglect of a child, an elder, or a vulnerable adult.
- Serious threat to health or safety. To prevent or lessen a serious and imminent threat to your safety or the safety of another person, shared only with someone able to help prevent the threat.
- Public health activities. For example, reporting certain diseases or preventing injury, as required by law.
- Health oversight. To agencies that audit, investigate, inspect, or license healthcare providers, such as the Wisconsin Department of Safety and Professional Services or the Ohio Counselor, Social Worker and Marriage and Family Therapist Board.
- Lawsuits and legal proceedings. In response to a court order. In response to a subpoena only when the law allows and, for mental health records, when Wisconsin or Ohio law permits it.
- Law enforcement. For limited purposes the law allows, such as responding to a court order or warrant.
- Coroners and medical examiners. To identify a person or determine a cause of death.
- Workers’ compensation. As required by workers’ compensation laws.
- Specialized government functions. For military, national security, or protective services, as the law requires.
- Research. Only when the law allows and with privacy protections approved by a review board.
4. Uses that require your written authorization
We will not do the following without your written authorization:
- Psychotherapy notes. Most uses and disclosures of psychotherapy notes (a therapist’s separate notes from sessions, kept apart from the rest of your record).
- Marketing. Using or sharing your PHI for marketing purposes.
- Sale of PHI. Selling your PHI. We do not sell PHI.
- Anything else not described in this Notice.
You may revoke an authorization at any time in writing. Revoking it does not undo anything we already did in reliance on it.
5. Your rights regarding your health information
To exercise any of these rights, contact us using the information at the end of this Notice.
- Right to access and get a copy. You may see or get a copy of your health records, in paper or electronic form. We will respond within 30 days and may charge a reasonable, cost-based fee.
- Right to request restrictions. You may ask us to limit how we use or share your PHI for treatment, payment, or healthcare operations. We are not required to agree, except as described in the next item.
- Right to restrict disclosures to your health plan. If you pay for a service in full out of pocket, you may ask us not to share information about that service with your health plan. We will agree unless the law requires us to share it.
- Right to confidential communications. You may ask us to contact you in a specific way or at a specific place, for example by email only or at a particular address. We will agree to reasonable requests.
- Right to amend. If you believe your information is incorrect or incomplete, you may ask us in writing to correct it. We may deny the request and will tell you why in writing.
- Right to an accounting of disclosures. You may ask for a list of the times we have shared your PHI in the six years before your request, other than for treatment, payment, healthcare operations, or disclosures you authorized. One list per year is free.
- Right to be notified of a breach. We will notify you if a breach affects your unsecured PHI.
- Right to a paper copy of this Notice. You may ask for a paper copy at any time, even if you received it electronically.
- Right to choose someone to act for you. If you have given someone medical power of attorney or someone is your legal guardian, that person can exercise your rights.
6. Sensitive information
Mental health treatment records, substance use disorder records, and HIV test results receive extra protection under state and federal law. When these laws are stricter than HIPAA, we follow them, and we will obtain any additional authorization they require before sharing this information.
Wisconsin. For clients located in Wisconsin, treatment records are protected under Wis. Stat. §§ 51.30 and 146.82.
Ohio. For clients located in Ohio, communications with a licensed social worker are privileged under Ohio Rev. Code § 2317.02(G). That privilege has limits: we may disclose information when there is a clear and present danger to you or another person, when you consent, as part of required reporting of suspected child abuse or neglect (Ohio Rev. Code § 2151.421), and when a clinician must act on an explicit threat of serious harm to an identifiable person (Ohio Rev. Code § 2305.51).
If we receive records from a federally assisted substance use disorder program (42 CFR Part 2), we will not use or disclose them in any civil, criminal, administrative, or legislative proceeding against you without your written consent or a court order that meets federal requirements.
7. Changes to this Notice
We may change the terms of this Notice, and the changes will apply to all information we hold about you. The current Notice is posted on this page and is available from us on request. The effective date at the top shows which version is in effect.
8. Complaints
If you believe your privacy rights have been violated, you may file a complaint with us using the contact information below, or with the U.S. Department of Health and Human Services Office for Civil Rights: 200 Independence Ave SW, Washington, DC 20201; 1-800-368-1019; hhs.gov/ocr/complaints.
Wisconsin residents may also contact the Wisconsin Department of Health Services. Ohio residents may also contact the Ohio Counselor, Social Worker and Marriage and Family Therapist Board, 77 S. High St., 24th Floor, Columbus, OH 43215, (614) 466-0912, cswmft.ohio.gov.
We will not retaliate against you or change your care in any way for filing a complaint.
9. Contact information
For questions about this Notice, to request a copy, or to exercise any of your rights, contact our Privacy Officer:
Mindset Studio, LLC
Attn: Tim Coughlin, LCSW, LISW, Privacy Officer
2800 E. Enterprise Ave, Ste 333, Appleton, WI 54913
(781) 718-3956 · tim@mindsetstudiohealth.com