Notice of Privacy Policies
Therapy with Jeni, LLC
Jenifer Saaraswath, MS, LPCC, DARTT
Effective Date: 02/16/2026
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. My Pledge Regarding Health Information
I understand that health information about you and your care is personal. I am committed to protecting your protected health information (“PHI”). I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements.
This Notice applies to all records of your care generated by this practice. It describes the ways in which I may use and disclose your PHI, your rights regarding your PHI, and my obligations under federal and state law.
I am required by law to:
- Maintain the privacy of your protected health information;
- Provide you with this Notice of my legal duties and privacy practices;
- Follow the terms of the Notice currently in effect; and
- Notify you following a breach of unsecured protected health information.
I reserve the right to change the terms of this Notice. Any changes will apply to all PHI I maintain. The revised Notice will be available upon request, in my office, and on my website (if applicable). The effective date will appear at the top of the Notice.
In accordance with Ohio Administrative Code 4757-5-09, Therapy with Jeni LLC maintains your records for seven years. If your therapist leaves Therapy with Jeni LLC, the record of your treatment history prior to the therapist leaving remains with the practice.
II. How I May Use and Disclose Health Information About You
The following categories describe ways I may use and disclose PHI. Not every possible use or disclosure is listed, but all permitted uses and disclosures fall within one of these categories.
All uses and disclosures described below are subject to federal limitations regarding reproductive health care and substance use disorder information.
A. For Treatment, Payment, or Health Care Operations
Federal privacy regulations permit health care providers with a direct treatment relationship to use or disclose PHI without written authorization for treatment, payment, and health care operations.
Treatment
I may use or disclose PHI to provide, coordinate, or manage your health care. This includes consultations, referrals, and coordination with other providers. Disclosures for treatment purposes are not limited to the “minimum necessary” standard.
Payment
I may use and disclose PHI to obtain payment for services provided to you.
Health Care Operations
I may use and disclose PHI for practice operations, including quality assessment, supervision, training, licensing, and compliance activities.
B. Lawsuits, Legal Proceedings, and Law Enforcement
I may disclose PHI in response to a court or administrative order.
I may also disclose PHI in response to a subpoena, discovery request, or other lawful process if legal requirements are met.
However, I am prohibited from using or disclosing PHI for the purpose of investigating or prosecuting any person in connection with lawful reproductive health care.
If a request involves reproductive health care information and falls within a category requiring additional safeguards (including law enforcement, health oversight activities, judicial or administrative proceedings, or disclosures to coroners or medical examiners), I will obtain a signed attestation confirming the request is not for a prohibited purpose before making the disclosure.
III. Uses and Disclosures That Require Your Written Authorization
Except as described in this Notice, I will not use or disclose your PHI without your written Authorization.
Uses and disclosures requiring Authorization include:
- Use or disclosure of psychotherapy notes (with limited exceptions described below);
- Use or disclosure of PHI for marketing purposes;
- Sale of PHI;
- Uses or disclosures not otherwise permitted by HIPAA;
- Certain uses and disclosures involving reproductive health care information not otherwise permitted by law.
You may revoke your Authorization at any time in writing, except to the extent that I have already relied on it.
Psychotherapy Notes
I maintain psychotherapy notes as defined in 45 CFR § 164.501. Any use or disclosure of psychotherapy notes requires your Authorization except:
- For my use in treating you;
- For training or supervising mental health practitioners;
- To defend myself in legal proceedings brought by you;
- For investigation by the Secretary of Health and Human Services;
- As required by law;
- For certain health oversight activities;
- To a coroner performing lawful duties;
- To avert a serious threat to health or safety.
Marketing
I will not use or disclose your PHI for marketing purposes without your written Authorization.
If I receive financial remuneration in exchange for making a communication about a product or service, your written Authorization is required.
Fundraising Communications
If I ever use PHI to send you fundraising communications, you will be given a clear and conspicuous opportunity to opt-out of receiving such communications.
Sale of PHI
I will not sell your PHI. Any disclosure that constitutes a sale of PHI under federal law requires your written Authorization.
IV. Uses and Disclosures That Do Not Require Authorization
Subject to legal limitations, I may use or disclose PHI without your Authorization:
- When required by federal or state law;
- For public health activities;
- To report suspected abuse or neglect;
- For health oversight activities;
- For judicial and administrative proceedings;
- For law enforcement purposes;
- To coroners or medical examiners;
- For research (under appropriate safeguards);
- For specialized government functions;
- For workers’ compensation purposes;
- For appointment reminders;
- To inform you of treatment alternatives or health-related benefits or services.
V. Disclosures Where You Have the Opportunity To Object
I may disclose PHI to a family member, friend, or other person involved in your care or payment for care, unless you object. In emergency circumstances, consent may be obtained retroactively.
VI. Your Rights Regarding Your PHI
You have the following rights:
Right to Request Restrictions
You may request restrictions on certain uses and disclosures. I am not required to agree, except where required by law.
Right to Restrict Disclosures to Health Plans
If you pay out-of-pocket in full for a service, you may request that I not disclose information about that service to your health plan. I must agree to this request unless disclosure is otherwise required by law.
Right to Confidential Communications
You may request that I communicate with you in a specific way or at a specific location. I will accommodate reasonable requests.
Right to Access and Copies
You may obtain an electronic or paper copy of your PHI (excluding psychotherapy notes). I will respond within 30 days and may charge a reasonable cost-based fee.
Requests should be submitted in writing to:
Therapy with Jeni LLC
4239 Hamilton Ave
Cincinnati, OH 45223
Right to an Accounting of Disclosures
You may request a list of certain disclosures made in the past six years (excluding treatment, payment, and operations). I will respond within 60 days.
Right to Amend
You may request correction of your PHI. I may deny the request but will respond in writing within 60 days.
Right to a Copy of This Notice
You may receive a paper or electronic copy of this Notice at any time.
Right to Be Notified of a Breach
You have the right to be notified if there is a breach of your unsecured protected health information.
VII. Special Protections for Reproductive Health Care Information
Federal law provides additional protections for PHI related to reproductive health care.
I am prohibited from using or disclosing PHI for the purpose of conducting a criminal, civil, or administrative investigation or proceeding against any person for seeking, obtaining, providing, or facilitating lawful reproductive health care.
When required by federal law, I will obtain a signed attestation from a requesting party confirming that the requested PHI is not for a prohibited purpose before making certain disclosures involving reproductive health care information.
VIII. Substance Use Disorder Records (42 C.F.R. Part 2)
Some records we receive or maintain may be protected under 42 CFR Part 2, which governs specialized substance use disorder records. These records are subject to stricter confidentiality standards than general medical information.
SUD treatment records received from programs subject to 42 CFR part 2, or testimony relaying the content of such records, shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against the individual unless based on written consent, or a court order after notice and an opportunity to be heard is provided to the individual or the holder of the record, as provided in 42 CFR part 2. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested record is used or disclosed.
Your Rights Concerning SUD Records
With respect to SUD records protected under Part 2, you have the following rights:
- Your SUD records may not be used or disclosed without your written consent unless specifically permitted by Part 2.
- SUD records may not be disclosed for use in civil, criminal, administrative, or legislative proceedings against you unless:
- You provide written consent; or
- A court issues an order after providing you and/or the record holder notice and an opportunity to be heard, consistent with Part 2 requirements.
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Notice of Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW MENTAL HEALTH AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes in most instances without your consent under HIPAA, but I will obtain consent in another form for disclosing PHI for other reasons, including disclosing PHI outside of my practice, except as otherwise outlined in this Policy. In all instances I will only disclose the minimum necessary information in order to accomplish the intended purpose. To help clarify these terms, here are some definitions:
• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment and Health Care Operations” – Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another therapist. - Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage, which would include an audit. - Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
• “Disclosure” applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances, when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information, including uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI. Examples of disclosures requiring an authorization include disclosures to your partner, your spouse, your children, except in some limited instances where they are involved in your health care, in which case I will obtain your consent first. Any disclosure involving psychotherapy notes, if I maintain them, will require your signed authorization, unless I am otherwise allowed or required by law to release them. You may revoke an authorization for future disclosures, but this will not be effective for past disclosures which you have authorized.
III. Uses and Disclosures Requiring Neither Consent nor Authorization I may use or disclose PHI without your consent or authorization as allowed by law, including under the following circumstances:
• Serious Threat to Health or Safety: If I believe that you pose a clear and substantial risk of imminent serious harm, or a clear and present danger, to yourself or another person I may disclose your relevant confidential information to public authorities, the potential victim, other professionals, and/or your family in order to protect against such harm. If you communicate to me an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly identifiable victims, and I believe you have the intent and ability to carry out the threat, then I may take one or more of the following actions in a timely manner:
- take steps to hospitalize you on an emergency basis,
- establish and undertake a treatment plan calculated to eliminate the possibility that you will carry out the threat, and initiate arrangements for a second opinion risk 2 assessment with another mental health professional,
- communicate to a law enforcement agency and, if feasible, to the potential victim(s), or victim's parent or guardian if a minor, all of the following information:
a) the nature of the threat,
b) your identity, and
c) the identity of the potential victim(s). I will inform you about these notices and obtain your written consent, if I deem it appropriate under the circumstances.
• Worker’s Compensation: If you file a worker’s compensation claim, I may be required to give your mental health information to relevant parties and officials.
• Felony Reporting: I am allowed to report any felony that you report to me that has been or is being committed.
• For Health Oversight Activities: I may use and disclose PHI if a government agency is requesting the information for health oversight activities. Some examples could be audits, investigations, or licensure and disciplinary activities conducted by agencies required by law to take specified actions to monitor health care providers, or reporting information to control disease, injury or disability.
• For Specific Governmental Functions: I may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, and for national security reasons, such as for protection of the President.
• For Lawsuits and Other Legal Proceedings: If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by law. I cannot provide any information without your (or your personal or legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
• Abuse, Neglect, and Domestic Violence: If I know or have reason to suspect that a child under 18 years of age or a developmentally disabled, or physically impaired child under 21 years of age has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect of the child or developmentally disabled individual under 21, the law requires that I file a report with the appropriate government agency, usually the County Children Services Agency. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to believe that a developmentally disabled adult, or an elderly adult in an independent living setting or in a nursing home is being abused, neglected, or exploited, the law requires that I report such belief to the appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. If I know or have reasonable cause to believe that a patient or client has been the victim of domestic violence, I must note that knowledge or belief and the basis for it in the patient’s or client’s records.
• To Coroners and Medical Examiners: I may disclose PHI to coroners and medical examiners to assist in the identification of a deceased person and to determine a cause of death.
• For Law Enforcement: I may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
• Required by Law. I will disclose health information about you when required to do so by federal, state or local law.
• Public Health Risks. I may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, non-accidental physical injuries, reactions to medications or problems with products.
• Information Not Personally Identifiable. I may use or disclose health information about you in a way that does not personally identify you or reveal who you are. Other uses and disclosures will require your signed authorization.
IV. Patient's Rights and Duties Patient’s Rights:
• Right to Request Restrictions and Disclosures–You have the right to request to your treatment provider verbally or in writing restrictions on certain uses and disclosures of protected health information about you for treatment, payment or health care operations. However, I am not required to agree to a restriction you request, except under certain limited circumstances, and will notify you if that is the case. One right that I may not deny is your right to request that no information be sent to your health care plan if payment in full is made for the health care service. If you select this option then you must request it ahead of time and payment must be received in full each time a service is going to be provided. I will then not send any information to the health care plan for that session unless I am required by law to release this information. 3
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request to your treatment provider verbally or in writing and receive confidential communications of PHI by alternative means and at alternative locations. If your request is reasonable, then I will honor it.
• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record, except under some limited circumstances. If I maintain the information in an electronic format you may obtain it in that format. This does not apply to information created for use in a civil, criminal or administrative action or proceeding. I may charge you reasonable amounts for copies, mailing or associated supplies under most circumstances. I may deny your request to inspect and/or copy your record or parts of your record in certain limited circumstances. If you are denied copies of or access to your PHI, you may ask that my denial be reviewed. Under certain stances where I feel, for clearly stated treatment reasons, the disclosure of your record might have an adverse effect on you, I will provide your records to another mental health therapist of your choice.
• Right to Amend – You have the right to request an amendment to your therapist of PHI for as long as the PHI is maintained in the record. I may deny your request, but will note that you made the request. Upon your request, I will discuss with you the details of the amendment process.
• Right to an Accounting – With certain exceptions, you generally have the right to receive an accounting of disclosures of PHI, not including disclosures for treatment, payment or health care operations for paper records on file for the past six years and for an accounting of disclosures made involving electronic records, including disclosures for treatment, payment or health care operations, for a period of three years. On your request I will discuss with you the details of the accounting process.
• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from your treatment provider upon request, even if you have agreed to receive the notice electronically.
My Duties:
• I am required by law to maintain the privacy of PHI, to provide you with this notice of my legal duties and privacy practices with respect to PHI, and to abide by the terms of this notice.
• I reserve the right to change the privacy policies and practices described in this notice and to make those changes effective for all of the PHI I maintain.
• If I revise my policies and procedures, which I reserve the right to do, I will make available a copy of the revised notice to you on my website, if I maintain one, and one will always be available at my office. You can always request that a paper copy be sent to you by mail.
• In the event that I learn that there has been an impermissible use or disclosure of your unsecured PHI, unless there is a low risk that your unsecured PHI has been compromised, I will notify you of this breach.
V. Complaints If you are concerned that I have violated your privacy rights, or you disagree with a decision I make about access to your records, you may file a complaint with me and I will consider how best to resolve your complaint. Contact me, the Privacy Officer, if you wish to file a complaint with me. In the event that you aren’t satisfied with my response to your complaint, or don’t want to first file a complaint with me, then you may send a written complaint to the Secretary of the U.S. Department of Health and Human Services in Washington, D.C.., 200 Independence Avenue S.W., Washington, D.C. 20201, Ph: 1-877-696-6775, or visiting
www.hhs.gov/ocr/privacy/hipaa/compliants/. There will be no retaliation against you for filing a complaint.
VI. Effective Date: This notice is effective as of January 1, 2023.
VII. Privacy and Security Officer I act as my own Privacy and Security Officer. My contact information is listed at the beginning of this form.
