Privacy Policy

Health Insurance Portability Accountability Act (HIPAA) Client Rights & Mental Health Professional Duties

This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.

HIPAA requires that MasterMind Clinic, PLLC provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations.  The Notice explains HIPAA and its application to your PHI in greater detail. 

The law requires that MasterMind Clinic, PLLC obtain your signature acknowledging that MasterMind Clinic, PLLC has provided you with this policy.  If you have any questions, it is your right and obligation to ask the office manager so MasterMind Clinic, PLLC staff member can have a further discussion prior to signing this document.  When you sign this document, it will also represent an agreement between us.  You may revoke this Agreement in writing at any time.  That revocation will be binding unless MasterMind Clinic, PLLC has taken action in reliance on it.


The law protects the privacy of all communication between a patient and mental health professional(s).  In most situations, MasterMind Clinic, PLLC can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA.  There are some situations where MasterMind Clinic, PLLC is permitted or required to disclose information without either your consent or authorization. If such a situation arises, MasterMind Clinic, PLLC will limit my disclosure to what is necessary.  Reasons MasterMind Clinic, PLLC may have to release your information without authorization:

  1. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law.  MasterMind Clinic, PLLC cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if MasterMind Clinic, PLLC receives a subpoena of which you have been properly notified and you have failed to inform MasterMind Clinic, PLLC that you oppose the subpoena.  If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order MasterMind Clinic, PLLC to disclose information.
  2. If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, MasterMind Clinic, PLLC may be required to provide it for them.
  3. If a patient files a complaint or lawsuit against MasterMind Clinic, PLLC, MasterMind Clinic, PLLC may disclose relevant information regarding that patient in order to defend ourselves.
  4. If a patient files a worker's compensation claim, and MasterMind Clinic, PLLC is providing necessary treatment related to that claim, MasterMind Clinic, PLLC must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider.
  5. MasterMind Clinic, PLLC may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.


There are some situations in which MasterMind Clinic, PLLC is legally obligated to take actions, which MasterMind Clinic, PLLC believes are necessary to attempt to protect others from harm, and MasterMind Clinic, PLLC may have to reveal some information about a patient's treatment:

  1. If MasterMind Clinic, PLLC knows or has reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that MasterMind Clinic, PLLC file a report with 911 if the person is in imminent danger or the Colorado Child Abuse and Neglect Hotline 1-844-CO4-KIDS (1-844-264-5437).  Once such a report is filed, MasterMind Clinic, PLLC may be required to provide additional information.
  2. If MasterMind Clinic, PLLC knows or has reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that MasterMind Clinic, PLLC file a report with 911 if the person is in imminent danger or the to the local law enforcement agency where the adult resides.  Once such a report is filed, MasterMind Clinic, PLLC may be required to provide additional information.
  3. If MasterMind Clinic, PLLC believes that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, MasterMind Clinic, PLLC may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.


Use and Disclosure of Protected Health Information:

For Treatment – MasterMind Clinic, PLLC use and disclose your health information internally in the course of your treatment.  If MasterMind Clinic, PLLC wish to provide information outside of our practice for your treatment by another health care provider, MasterMind Clinic, PLLC will have you sign an authorization for release of information.  Furthermore, an authorization is required for most uses and disclosures of patient chart or records.

For Payment – MasterMind Clinic, PLLC may use and disclose your health information to obtain payment for services provided to you as delineated in the disclosure and agreement for assignment of benefits.

For Operations – MasterMind Clinic, PLLC may use and disclose your health information as part of our internal operations.  For example, this could mean a review of records to assure quality.  MasterMind Clinic, PLLC may also use your information to tell you about services, educational activities, and programs that MasterMind Clinic, PLLC feel might benefit you or be of interest to you.

Patient's Rights:

Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.

Right to Confidentiality – You have the right to have your health care information protected.  If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.  MasterMind Clinic, PLLC will agree to such unless a law requires us to share that information.

Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, MasterMind Clinic, PLLC is not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.

Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI.  Records must be requested in writing and release of information must be completed.  Furthermore, there is a copying fee allow by Colorado Statute.  Please make your request well in advance and allow 2 weeks to receive the copies.  To receive the requested records, the fee and a current state or federal identification must be presented.

Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information.  You have to make this request in writing.  You must tell us the reasons you want to make these changes, and MasterMind Clinic, PLLC will decide if it is and if MasterMind Clinic, PLLC refuse to do so, MasterMind Clinic, PLLC will tell you why within 60 days. 

Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email.  If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.

Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you.  On your request, MasterMind Clinic, PLLC will discuss with you the details of the accounting process.

Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; MasterMind Clinic, PLLC will make sure the person has this authority and can act for you before MasterMind Clinic, PLLC take any action.  MasterMind Clinic, PLLC will have to be given a copy of the legal court documents designating the legal guardian and a current identification.  Copies of these documents must be kept on file in the EHR.  If using a POA, the documents must be kept on file with a copy of the current identification.  You may designate a person to be contacted or to represent you, make appointments, and aid in managing your mental health care.  You will need to provide a release of information (ROI) indicating what the person is permitted to do on your behalf.  The ROI is only valid for 12 months and then must be renewed.

Right to Choose – You have the right to decide not to receive services with MasterMind Clinic, PLLC.  If you wish, MasterMind Clinic, PLLC will provide you with names of other qualified mental health professionals. 

Right to Terminate – You have the right to terminate mental health or therapeutic services with MasterMind Clinic, PLLC at any time without any legal or financial obligations other than those already accrued.  MasterMind Clinic, PLLC asks that you discuss your decision with MasterMind Clinic, PLLC staff members during an appointment or upon request, before terminating or at least contact MasterMind Clinic, PLLC by phone letting the staff know you are terminating services.

Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate.

Nurse Practitioners, Therapist, and all Staff’s Responsibilities and Duties:

MasterMind Clinic, PLLC is required by law to maintain the privacy of all PHI and to provide you with a notice of our responsibilities, legal duties and privacy practices with respect to PHI.  MasterMind Clinic, PLLC reserve the right to change the privacy policies and practices described in this notice.  Unless MasterMind Clinic, PLLC notifies you of such changes, however, MasterMind Clinic, PLLC is required to abide by the terms currently in effect.  If MasterMind Clinic, PLLC revise the policies and procedures, MasterMind Clinic, PLLC will provide you with a revised notice on the website or upon request.


If you are concerned that MasterMind Clinic, PLLC, any MasterMind Clinic, PLLC employee or independent contractor has violated your privacy rights, or you disagree with a decision by a MasterMind Clinic, PLLC employee or independent contractor has made about access to your records, you may contact the MasterMind Clinic, PLLC office manager, the State of Colorado Department of Health, or the Secretary of the U.S. Department of Health and Human Services.