HIPAA NOTICE OF PRIVACY PRACTICES

Premier Psychology of Indiana, LLC
Effective Date: September 29, 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.

This Notice of Privacy Practices describes how Premier Psychology of Indiana, LLC may use and disclose protected health information (“PHI”) and explains your rights regarding that information. PHI includes information that identifies an individual and relates to their physical or mental health, health care services, or payment for health care.

When the patient is a minor, references in this Notice to “you” or “your” generally include the patient's parent, legal guardian, or other personal representative to the extent permitted by applicable law.

YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities.

Get an electronic or paper copy of your health information

You may ask to inspect or obtain an electronic or paper copy of health information maintained about you or your child.

We will provide access to or a copy of your health information as required by law, generally within the time period required by applicable law. In certain circumstances, access to some information may be limited or denied as permitted by law. When applicable, you may have the right to have a denial of access reviewed.

If a fee is charged for providing copies, the fee will be limited to amounts permitted by applicable law.

Ask us to correct your health information

You may ask us to correct or amend health information about you or your child that you believe is incorrect or incomplete.

We may deny your request under circumstances permitted by law. If your request is denied, we will provide information regarding the denial and any rights you may have to submit a written statement of disagreement.

Request confidential communications

You may ask us to contact you in a specific way or at a specific location, such as using a particular telephone number, email address, or mailing address.

We will accommodate reasonable requests as required by law.

Ask us to limit what we use or disclose

You may ask us not to use or disclose certain health information for treatment, payment, or health care operations. We are generally not required to agree to your request, and we may decline a request when permitted by law.

If you pay for a health care service or item out-of-pocket in full, you may ask us not to disclose information about that service or item to your health plan for payment or health care operations purposes. We will honor that request unless disclosure is required by law.

Obtain a list of certain disclosures

You may request an accounting of certain disclosures of your health information made during the six years preceding the date of your request, including information about whom we disclosed it to and why.

The accounting will not include disclosures excluded from this requirement under applicable law, such as many disclosures made for treatment, payment, or health care operations and certain disclosures that you specifically requested or authorized.

We will provide one accounting during any 12-month period without charge. We may charge a reasonable, cost-based fee for additional requests during the same 12-month period, as permitted by law.

Obtain a copy of this Notice

You may request a paper copy of this Notice at any time, even if you previously agreed to receive it electronically. We will provide a paper copy promptly.

Choose someone to act on your behalf

If another individual has legal authority to act on your behalf, such as a legal guardian, personal representative, or person holding an applicable health care power of attorney, that person may exercise your rights and make choices regarding your health information as permitted by law.

We may verify the person's authority before taking action on a request.

File a complaint if you believe your privacy rights have been violated

You may file a complaint with Premier Psychology of Indiana if you believe your privacy rights have been violated by contacting the Privacy Contact listed at the end of this Notice.

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.

Premier Psychology of Indiana will not retaliate against you or deny services because you file a privacy complaint.

YOUR CHOICES

For certain health information, you may tell us your preferences about what we disclose.

Family, friends, caregivers, and others involved in your care

When appropriate and permitted by law, you may tell us whether we may share relevant health information with family members, friends, caregivers, or others involved in your care or payment for your care.

We may also disclose information when appropriate for disaster-relief purposes.

If you are unable to communicate your preference, we may disclose relevant information when permitted by law and when, in our professional judgment, doing so is in your best interest.

Marketing, sale of information, and psychotherapy notes

We will obtain your written authorization before using or disclosing PHI when authorization is required by law, including:

most uses and disclosures of psychotherapy notes, if applicable;
most uses and disclosures for marketing purposes; and
the sale of PHI.

You may revoke an authorization in writing at any time, except to the extent that we have already acted in reliance upon it.

Fundraising

Premier Psychology of Indiana does not use PHI to contact patients or families for fundraising purposes.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

HIPAA and other applicable laws permit or require us to use or disclose PHI in certain circumstances without obtaining your written authorization. The following describes common ways in which we may use and disclose your information.

Treatment

We may use and disclose your PHI to provide, coordinate, or manage your care.

For example, when permitted by law, we may communicate with another health care professional involved in your care regarding evaluation findings, treatment needs, or recommendations.

Payment

We may use and disclose PHI for activities necessary to obtain or facilitate payment for health care services.

For example, we may process payment for services, provide documentation requested in connection with reimbursement, or communicate with a health plan or other payer when authorized or otherwise permitted by law.

Health care operations

We may use and disclose PHI as necessary to operate our practice.

For example, we may use PHI for quality assessment and improvement, professional consultation, licensing or credentialing activities, legal or administrative services, business management, compliance activities, and other health care operations permitted by law.

Business associates

We may disclose PHI to third parties that perform services or functions on behalf of Premier Psychology of Indiana involving PHI.

When required by HIPAA, these business associates are contractually required to appropriately safeguard PHI.

Help with public health and safety activities

We may disclose PHI for certain public health and safety activities as permitted or required by law.

These activities may include preventing or controlling disease, reporting adverse events or product problems when applicable, and other legally authorized public health activities.

Report suspected abuse or neglect

We may disclose PHI to appropriate governmental or other authorities when reporting suspected abuse or neglect is required or permitted by law.

Prevent or lessen a serious threat to health or safety

We may use or disclose PHI when necessary and permitted by law to prevent or lessen a serious and imminent threat to the health or safety of an individual or the public. Any such disclosure will be made to a person or entity reasonably able to help prevent or lessen the threat.

Comply with health oversight activities

We may disclose PHI to authorized health oversight agencies for activities authorized by law, such as audits, investigations, inspections, professional licensing or disciplinary proceedings, and other oversight activities.

Respond to lawsuits and legal proceedings

We may disclose PHI in response to a valid court order, subpoena, discovery request, administrative proceeding, or other lawful process when disclosure is permitted or required by applicable law.

Psychological records, privileged communications, test materials, substance use disorder records, and other specially protected information may be subject to additional protections or restrictions under federal or state law. We will comply with applicable requirements before disclosing such information.

Respond to law enforcement requests

We may disclose PHI to law enforcement officials when permitted or required by law.

Comply with workers' compensation laws

We may disclose PHI as authorized by and to the extent necessary to comply with workers' compensation laws and similar programs established by law.

Work with coroners, medical examiners, and funeral directors

We may disclose PHI to coroners, medical examiners, and funeral directors when permitted or required by law for purposes such as identification, determining cause of death, or carrying out other legally authorized duties.

Respond to organ and tissue donation requests

When applicable, we may disclose PHI to organizations involved in organ, eye, or tissue donation and transplantation as permitted by law.

Assist with certain government functions

We may disclose PHI for certain specialized government functions when permitted by law, including military and veterans' activities, national security and intelligence activities, protective services, and correctional or custodial situations.

Conduct research

We may use or disclose PHI for health research when permitted by law and when applicable legal requirements for authorization, waiver, or other approval have been satisfied.

Comply with the law

We may use or disclose PHI when federal, state, or other applicable law requires us to do so.

SUBSTANCE USE DISORDER RECORDS

Certain substance use disorder (“SUD”) patient records are protected by additional federal confidentiality requirements under 42 U.S.C. § 290dd-2 and 42 CFR Part 2.

If Premier Psychology of Indiana creates or maintains records that are subject to Part 2, those records will be used and disclosed in accordance with applicable federal law.

When applicable, a patient may provide a single consent for future uses and disclosures of Part 2 records for treatment, payment, and health care operations as permitted by law. Records disclosed pursuant to such consent may be redisclosed as permitted by HIPAA, except that Part 2 records remain subject to restrictions on their use and disclosure in civil, criminal, administrative, and legislative proceedings against the patient.

Part 2 records generally may not be used or disclosed in a civil, criminal, administrative, or legislative proceeding against a patient without the patient's written consent or a court order that satisfies applicable Part 2 requirements.

Nothing in this Notice is intended to reduce any additional confidentiality protection provided by federal or state law.

OUR RESPONSIBILITIES

Premier Psychology of Indiana is required by law to maintain the privacy and security of your protected health information.

We are required to provide you with this Notice describing our legal duties and privacy practices and to follow the duties and privacy practices described in the Notice currently in effect.

We will notify affected individuals as required by law if a breach occurs that may have compromised the privacy or security of unsecured PHI.

We will not use or disclose your PHI other than as described in this Notice or otherwise permitted or required by law unless you provide written authorization.

If you provide written authorization, you may revoke it in writing at any time, except to the extent that we have already acted in reliance upon it.

Where another applicable federal or state law provides greater privacy protections or imposes greater restrictions on the use or disclosure of health information, Premier Psychology of Indiana will comply with the more protective law to the extent required.

CHANGES TO THE TERMS OF THIS NOTICE

Premier Psychology of Indiana may change the terms of this Notice and its privacy practices as permitted by law. Changes may apply to all PHI maintained by the practice, including information created or received before the change.

If this Notice is materially revised, the revised Notice will contain a new effective date and will be made available as required by law.

The current Notice will be available upon request, in our office, and on the Premier Psychology of Indiana website.

QUESTIONS OR COMPLAINTS

If you have questions about this Notice, would like additional information regarding your privacy rights, or believe your privacy rights have been violated, please contact:

Jennifer L. Godar, Psy.D., HSPP
Privacy Contact
Premier Psychology of Indiana, LLC
Telephone: 317-975-1896
Email: info@premierpsychologyllc.com

You may also file a complaint with:

U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775