Notice of Policies and Practices to Protect the Privacy of Your Health Information for Mantra Mental Health, LLC / Samantha Bergstein, MA, MSW, LISW 3630 North High St., Ste. 203, Columbus, OH 43214 / Ph: 614.984.4394

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:

“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. Please note, insurance/healthcare reimbursement may not cover the entirety of your session cost.

“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.

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.


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:
1) take steps to hospitalize you on an emergency basis
2) 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 assessment with another mental health professional
3) 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, or at times an administrative subpoena, unless the information was prepared for a third party. 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.


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, unless the use or disclosure is allowed or required by law.


Patient's Rights and Duties


Patient’s Rights:


Right to Request Restrictions and Disclosures–You have the right to request 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.



You have the right to request 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 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 me upon request, even if you have agreed to receive the notice electronically. You will not be automatically provided a paper copy unless requested.


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 or on the client portal, 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.

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


There will be no retaliation against you for filing a complaint.


Effective Date:
This notice is effective as of August 1, 2020.


Privacy and Security Officer:
I, Samantha Bergstein, MSW LISW, act as my own Privacy and Security Officer. My contact information is listed at the beginning of this form. I have sought expert legal, ethical, and clinical guidance regarding Privacy and Security best practices.

​More considerations



Legal Situations


If you or the client (if the client is a minor or a ward of a guardian) become involved in legal proceedings that require my participation you will be expected to pay for all of my professional time, even if I am called to testify by another party. I will ask that a retainer be paid of half of the expected fees at least one week prior to providing these services, and the second half of expected fees and any additional fees that may  have  been  accrued  be  paid  within  one  week  after  services  are delivered.  Any unused amounts will be refunded. My professional time for legal proceedings may  include  preparation, document  review or letter  preparation, phone consultation with other professionals or you, record copying fees, and travel time to and from proceedings, testifying, and time that I wait in court prior to or after I may be called to testify. Due to the time-consuming and often difficult nature of legal involvement, I charge $100.00 per hour for these services. You will also be responsible for any legal fees that I may incur in connection with the legal proceeding, which may include responding to subpoenas.

Professional Records


The laws and standards of my profession require that I keep Protected Health Information about you in your client file. Your client file may include information about your reasons for seeking therapy, a description of the ways in which your problems affect your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, any payment records, and copies of any reports that have been sent to anyone. You may examine and/or receive a copy of all of your records that I have prepared in connection with your treatment if you request them in writing, unless I determine for clearly stated  treatment reasons that disclosure of the records to you is likely to have an adverse effect on you, and in that event under Ohio law I may exercise the option of turning the records over to another mental health therapist designated by you, unless otherwise required by federal law.  Because these are professional records they can be misinterpreted and/or upsetting to untrained readers, I therefore recommend that you initially review them with me or have them forwarded to another mental health professional so you can discuss the contents.  In most circumstances, I am allowed to charge fees set under Ohio and federal laws for copying and sending records.  These fees may change every year, so I will let you know what the charge is at the time that a records request is made. If you desire to have the information sent to you electronically, if I maintain the information in an electronic format, I will provide the information in that format if you agree to accept the potential risks involved in sending the information that way.


As your therapist, I will keep a set of psychotherapy notes which are for my own use and which are designed to assist me in providing you with the best treatment. These notes are kept separate from the rest of your records. In order for psychotherapy notes to be released to third parties, you must sign a separate authorization in addition to one for the rest of your records.





If you are under 18 years of age, please be aware that the law generally provides your parents the right to examine your treatment records, unless blocked by court order or if I feel that the release of your records to your parents might have an adverse effect on you, in which case under Ohio law they can name another mental health therapist that I will have to turn them over to, unless otherwise required by federal law. Before giving parents any information I will discuss the matter with you, if possible, and do my best to handle any objections you may have. Except in unusual circumstances, I like to make both parents aware of and involved in the treatment. In addition, if one parent brings in a child and the therapy only involves the child, under Ohio law since generally both parents have access to the child’s records unless that access is blocked by a court order, anything that either parent says in the sessions is available to both parents. Legal documents need to be provided in cases where custody, visitation, shared parenting, guardianship or other matters which are covered by court documents are involved before I see a minor for treatment. Minors 14 years of age and older should be aware that they have an option to see me on a limited basis without their parents’ knowledge, except where there is a compelling need for disclosure based on a substantial probability of harm to the minor or to other persons, and if the minor is notified of my intent to inform the minor’s parent, or guardian. Only the minor is responsible for paying for services under this option.


Incapacity or Death of Therapist


In the event that I am incapacitated or die, it will be necessary for another therapist to take possession of your file and records. By signing this form you consent to allow another licensed mental health professional whom I designate to take possession of your file and records, provide you with copies upon request, or to deliver them to a therapist of your choice.


Disclosing Information to Family Members, Relatives, or Close Friends


By signing this document you agree to allow me, if you are incapacitated, in an emergency situation, or are not available, to contact a family member, a relative, a close friend or any other person you identify, and disclose your personal health information that directly relates to that person’s involvement in your healthcare. This information will be disclosed as necessary only if I determine that it is your best interest based on my professional judgment.



Email, Texting, and Electronic Communications


I do not like to use e-mail, texting, or electronic communications unless we both agree that is appropriate. If you decide you want do not want to utilize any form of electronic communication, please let me know. By contacting me via email, text, or other electronic communications you acknowledge that there are confidentiality risks inherent in such communications if they are unencrypted and you agree to accept those risks. Please note that due to COVID19 and me conducting all sessions via telehealth, it may be difficult or impossible to hold sessions without some electronic communication. If this is an issue for you, we can discuss referral options to an alternate provider who may provide in-person sessions at this time.

Columbus, OH 43214
Email: Tel: (614) 984-4394
Fax: (614)319-5618