Notice of Privacy Practices
Effective Date: April 17, 2025
Rebel Heart Therapy LLC
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN ACCESS THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
At Rebel Heart Therapy, we are committed to protecting your privacy. This Notice of Privacy Practices (“Notice”) explains how we may use or disclose your health information and your legal rights under the Health Insurance Portability and Accountability Act (HIPAA).
The term “Protected Health Information” (PHI) refers to any information about your health, the care you receive, or payment for services that can identify you.
Our Responsibilities
We are required by law to maintain the privacy and security of your PHI.
We must follow the duties and privacy practices described in this Notice.
We will notify you promptly if a breach occurs that may have compromised the privacy or security of your information.
We reserve the right to change the terms of this Notice. If we do, we will make the new Notice available on our website and upon request.
Your Rights
You have several rights related to your PHI. To exercise any of these rights, submit a written request to the address listed at the end of this document.
Right to Access Your Records
You can request to see or get an electronic or paper copy of your health records.
We may charge a reasonable, cost-based fee.
We may deny access in limited circumstances (e.g., if it may endanger you or someone else), but you may request a review of that decision.
Right to Request Amendments
If you believe that information we have is incorrect or incomplete, you can request a correction.
We may deny your request, but will explain why in writing and allow you to add a statement of disagreement to your record.
Right to Request Confidential Communications
You can ask us to contact you in a specific way (for example, only at work or by text).
We will accommodate all reasonable requests.
Right to Request Restrictions
You can request that we limit what information we use or share.
We are not required to agree, especially if it would affect your care.
If you pay out-of-pocket in full for a service, you can request that we not share that information with your insurance — and we will honor that request.
Right to an Accounting of Disclosures
You can request a list (an “accounting”) of disclosures we’ve made of your PHI in the last six years, excluding routine disclosures for treatment, payment, or health care operations.
You may receive one free accounting per year; additional requests may include a reasonable fee.
Right to Receive a Copy of This Notice
You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.
Right to Choose Someone to Act for You
If you have given someone medical power of attorney or are under legal guardianship, that person can exercise your rights and make decisions on your behalf.
Right to File a Complaint
If you believe your privacy rights have been violated, you may file a complaint with:
Rebel Heart Therapy
11 NE MLK Blvd, Suite 203
Portland, OR 97232
Phone: 971-350-1122
Email: hello@rebelheartpdx.com
You may also contact the U.S. Department of Health and Human Services, Office for Civil Rights:
200 Independence Avenue, S.W., Washington, D.C. 20201
Phone: 1-877-696-6775
Website: www.hhs.gov/ocr/privacy/hipaa/complaints/
We will never retaliate against you for filing a complaint.
How We May Use and Share Your Health Information
We may use or share your PHI in the following ways without your written authorization:
For Treatment
We may share your PHI with other health care professionals involved in your care.
Example: A psychiatrist coordinating medication management with your clinician.
For Payment
We may use your PHI to bill and receive payment from health plans or other payers.
Example: Submitting your diagnosis and session information to your insurance.
For Health Care Operations
We may use your PHI to manage our practice, improve your care, and contact you about scheduling.
Example: Sending reminders about upcoming appointments.
Other Permitted Disclosures Without Authorization
We may also disclose your PHI when required or allowed by law, including:
Public health and safety activities (e.g., reporting abuse, disease prevention)
Health oversight activities (e.g., audits, inspections)
Legal proceedings (e.g., court orders, subpoenas)
Law enforcement
Coroners, medical examiners, and funeral directors
Organ donation
Workers’ compensation
National security and intelligence activities
Correctional institutions (for inmates receiving treatment)
Business associates (such as billing services under HIPAA-compliant agreements)
Disclosures With Opportunity to Object
We may share your PHI with:
A friend, family member, or other individual involved in your care, unless you object.
Emergency situations or when you’re unable to express your preferences, and we determine sharing is in your best interest.
Uses and Disclosures Requiring Written Authorization
We will obtain your written authorization for:
Marketing purposes
The sale of PHI
Sharing psychotherapy notes
Special Note on Psychotherapy Notes
Psychotherapy notes are separate from your general health record and are given special protection under HIPAA. We will never share your psychotherapy notes without your written consent, except as required by law.
You may revoke an authorization at any time in writing. Revocation does not apply to disclosures already made based on prior authorization.
Breach Notification
If your PHI is involved in a data breach, we are required by law to notify you promptly. We will inform you of what happened, what information was involved, and what steps you can take to protect yourself.
Questions or Complaints
If you have questions about this Notice or your privacy rights, please contact:
Tamara Werner
Rebel Heart Therapy
11 NE MLK Blvd, Suite 203
Portland, OR 97232
Phone: 971-350-1122
Email: behindthescenes@rebelheartpdx.com
To download a copy of the Notice of Privacy Practices, click here.