MARY CLAIRE KERWIN, LCSW

HIPAA COMPLIANCE PRIVACY NOTICE

YOUR INFORMATION, YOUR RIGHTS, OUR RESPONSIBILITIES

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.

Name of Therapist/Practice: Mary Claire Kerwin, LCSW

Phone: 931.216.4943

Email: marykerwintherapy@outlook.com

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

Your health record contains personal information about you that may identify you and that relates to your past, present and future physical or mental health or condition and related health services is referred to as Protected Health Information (PHI). This notice of privacy practice describes how we may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

I am required by law to maintain the privacy of PHI and to provide you with notice of your legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request, or providing you one at your next appointment.

HOW I USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordination, or managing your health care treatment and related services. This includes consultation with clinical supervisors, collaborating physicians, supervising physicians or peer review members. I may disclose PHI to any other consultant ONLY with your authorization.

For Health Care Operations: We may use or disclose, as needed, your PHI in order to support our
business activities including, but not limited to quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with the third parties that perform various (ex: billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes, PHI will only be disclosed with your authorization. Your PHI will also be used to remind you of your appointments.

Uses and Disclosures Requiring Authorizations: We may use or you may give written permission which allows us to use or disclose PHI for purposes other than treatment, payment or healthcare operations. We will always obtain your written permission before releasing your progress notes which are notes about our conversations during private, group, joint, or family sessions. These notes are often given a greater degree of protection than PHI.
Revocation of Authorization: You may revoke this authorization at any time, in writing, except to the extent that your provider or the provider's practice has taken an action on the use or disclosure indicated in the authorization. If the authorization was obtained as a condition of obtaining insurance coverage and the law provides the insurer the right to contest the claim under the policy, you may not revoke this authorization. Completed by Griselda Vera on Jul 09, 2026 at 01:51 PM - Client ID: 14992 Page 1 of 3

Uses and Disclosures Without Consent or Authorization: We may use or disclose PHI without your consent or authorization in the following circumstances: instances of child abuse, instances of adult and domestic abuse of disabled adult, health oversight, judicial or administrative proceedings only as required by law, serious threat to health or safety, medical emergency, worker's comp claims, or as required by law.

YOUR RIGHTS REGARDING YOUR PHI: You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to your provider.
*Right to access to Inspect and copy: You have the right, which may be restricted only in exceptional circumstances to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you.
*Right to request amendment: If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to mend the information, although we are not required to agree to amendment.
*Right to an accounting of Disclosures: You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any twelve-month period.
*Right to request restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
*Right to request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
*Right to a Copy of this Notice: You have a right to a copy of this notice.

COMPLAINTS: If you believe we have violated your privacy rights and wish to file a complaint with this office, you may send your written complaint to this office or you may contact your provider. You may also send a written complaint to the Secretary of the US Department of Health and Human Services. You have specific rights under the Privacy Rules. No retaliation will be taken against you for exercising your rights.

Use and Disclosure of Substance Use Disorder Records

If applicable, your substance use disorder (“SUD”) records are protected by federal law under 42 C.F.R.

This law provides extra confidentiality protection 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: (a) Medical Emergencies: to the extent necessary to treat you, (b) Reporting Crimes on Program Premises, (c) Child Abuse Reporting: In connection with incidents of suspected child abuse or neglect to appropriate state or local authorities.

 
Prohibitions on Use and Disclosure of Records:
SUD records received from programs subject to 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 disclosures, consistent with the other provisions in this Notice regarding PHI.