THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on my website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations. As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.

Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.

Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Research. PHI may only be disclosed after a special approval process or with your authorization.

Verbal Permission. I may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

Fundraising. We may send you special speaking engagements/fundraising communications at one time or another. You have the right to opt-out of such communications with each solicitation you receive.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that I have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request to Hayley Minger-Marlow at 21366 Hall Road, Unit #4092, Clinton Township, MI 48038:

· Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.

· Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with me. We may prepare a rebuttal to your statement and will provide you with a copy. Please let us know if you have any concerns/questions.

· Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

· Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

· Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.

· Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.

· Right to a Copy of this Notice. You have the right to a copy of this notice.

COMPLAINTS

If you believe we have violated your privacy rights, please discuss your concerns with us. You have the right to file a complaint in writing with our Privacy Officer, Hayley Minger-Marlow at 21366 Hall Road, Unit #4092, Clinton Township, MI 48038 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.

The effective date of this Notice is January 2026.

Purpose:
To establish clear guidelines for client communication with therapists and administrative staff, ensuring appropriate, professional, and timely responses.

Policy Statement:
Mental Mix Therapy PLLC is committed to maintaining professional boundaries while providing responsive communication to clients. This policy outlines appropriate communication methods, response times, and limitations on therapist availability outside of scheduled sessions.

Acceptable Communication Methods:

1.        Scheduling and Administrative Inquiries:

o   Clients may contact the clinic via phone at 313-380-0179 or email hayley@mentalmixtherapy.com for scheduling, rescheduling, or administrative questions.

o   Text messaging, if used, should be limited to appointment-related inquiries and confirmations.

2.        Therapist Communication:

o   Direct communication with therapists outside of scheduled sessions is strictly for scheduling-related concerns only.

o   Therapists do not engage in clinical discussions, therapeutic interventions, or crisis support outside of scheduled appointments.

o   If a client has a clinical concern, they should bring it to their next session or schedule an additional session if needed.

Response Time Expectations:

·       The clinic aims to respond to emails, voicemails, and texts within 24 business hours (Monday–Friday, excluding holidays and weekends).

·       Urgent matters should be directed to the Michigan Crisis and Access Line at 988 or the Crisis Text Line at 741741 as therapists and administrative staff do not provide emergency services.

Emergency and Crisis Situations:

·       This clinic does not provide emergency mental health services.

·       If a client is experiencing a crisis, they should contact 911, go to the nearest emergency room, or reach out to Michigan Crisis and Access Line at 988.

Inappropriate Communication:

·       Clients are expected to use communication channels professionally and appropriately.

·       Harassment, excessive messaging, or inappropriate contact may result in termination of services.

·       Social media, personal phone numbers, and informal messaging platforms are not appropriate methods of communication with therapists.

Purpose:
To protect the privacy and confidentiality of client information in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable federal and state laws.

Policy Statement:
Mental Mix Therapy PLLC is committed to maintaining the confidentiality of all client information and ensuring compliance with HIPAA regulations. This policy outlines the rights of clients, the responsibilities of the clinic, and procedures for handling protected health information (PHI).

Confidentiality of Client Information:

1.        Protected Health Information (PHI):

o   PHI includes any information related to a client’s health condition, treatment, or payment that can identify the client.

o   PHI may be stored in electronic, paper, or verbal form and is protected under this policy.

2.        Client Rights Under HIPAA:

o   The right to receive a copy of their medical records.

o   The right to request corrections to inaccurate information.

o   The right to request restrictions on the use or disclosure of their PHI.

o   The right to receive an accounting of disclosures of their PHI.

o   The right to file a complaint if they believe their rights have been violated.

Use and Disclosure of PHI:

1.        Permitted Uses and Disclosures Without Client Authorization:

o   Treatment: Sharing necessary PHI with healthcare providers involved in the client’s care.

o   Payment: Disclosing PHI to insurers or billing entities for payment purposes.

o   Healthcare Operations: Using PHI for internal quality assessment, training, and compliance audits.

o   Legal Requirements: Disclosing PHI when required by law, such as court orders or mandated reporting of abuse.

2.        Uses and Disclosures Requiring Client Authorization:

o   Any disclosures outside of treatment, payment, or healthcare operations require a signed authorization from the client.

o   Clients have the right to revoke authorization at any time, except when disclosure has already occurred.

Safeguarding Client Information:

·       Electronic Records: Access to electronic health records (EHR) is restricted to authorized staff only.

·       Paper Records: Physical files are stored in locked cabinets in a secure location.

·       Verbal Communication: Staff should avoid discussing PHI in public areas or non-secure settings.

·       Email and Electronic Communication: PHI should only be transmitted through encrypted and secure channels.

Reporting and Breach Notification:

1.        Reporting Violations:

o   Any suspected or actual breaches of client confidentiality must be reported immediately to Hayley Minger-Marlow at hayley@mentalmixtherapy.com.

o   Staff members who violate confidentiality policies may be subject to disciplinary action.

2.        Breach Notification:

o   In the event of an unauthorized disclosure of PHI, affected clients will be notified as required by HIPAA.

The clinic will take corrective action to prevent future breaches.

Purpose:
To provide clear guidelines for handling emergency and crisis situations involving clients, ensuring safety, appropriate response, and adherence to legal and ethical standards.

Policy Statement:
Mental Mix Therapy PLLC is an outpatient mental health clinic and does not provide crisis intervention or emergency services. Therapists are in session with other clients and do not have the capacity to act as a crisis resource. Clients experiencing an immediate crisis should seek assistance from emergency services or crisis resources.

Definition of a Crisis:
A crisis is defined as any situation where a client:

·       Is at immediate risk of harming themselves or others.

·       Is experiencing a severe psychiatric episode that requires urgent intervention.

·       Requires immediate medical attention due to a mental health condition.

Emergency Contact Information:
Clients experiencing an emergency should contact one of the following:

·       911 – For immediate medical or safety emergencies.

·       988 Suicide & Crisis Lifeline – Call or text 988 for 24/7 crisis support.

·       Crisis Text Line – Text HOME to 741741 for 24/7 crisis support.

·       DMC Detroit Receiving Hospital- Crisis Center –  Call 313-745-3506 for crisis support.

Therapist and Clinic Role in a Crisis:

1.        During Business Hours:

o   If a client contacts the clinic in distress, administrative staff will direct them to emergency services or appropriate crisis resources.

o   Therapists are in session with other clients and cannot respond to crisis situations. Clients must seek immediate assistance through emergency services.

2.        After Business Hours:

o   The clinic does not provide after-hours crisis services.

o   Clients should utilize 911, 988, or local crisis resources.

3.        Mandated Reporting:

o   If a client expresses intent to harm themselves or others, the therapist is legally obligated to take necessary steps, including notifying emergency services or identified support persons.

o   In cases of suspected abuse or neglect, therapists are required to report to the appropriate authorities.

Wellness and Safety Planning:

·       Clients at risk of crisis should work with their therapist to develop a personalized safety plan, including identifying support systems and coping strategies.

·       Clients are encouraged to share emergency contact information with the clinic in case of a crisis requiring outreach.

Purpose:
To ensure clarity and transparency regarding financial responsibilities, payment expectations, and billing procedures for all clients receiving services at Mental Mix Therapy PLLC.

Policy Statement:
All clients are responsible for payment of services rendered, including any fees not covered by insurance. This policy outlines the clinic’s procedures regarding payment collection, insurance billing, and financial agreements.

Payment Responsibility:

1.        Insurance Billing:

o   The clinic will submit claims to the client’s insurance provider.

o   Clients are responsible for understanding their insurance benefits, including deductibles, copayments, and coinsurance.

o   If a claim is denied or unpaid by the insurer, the client is responsible for the full balance.

2.        Self-Pay Clients:

o   Clients without insurance or those choosing not to use insurance must pay the full session fee at the time of service.

o   A sliding scale fee may be available for eligible clients based on financial need.

3.        Copays and Deductibles:

o   Copayments are due at the time of service.

o   If a deductible has not been met, the client is responsible for any portion of the session fee not covered by insurance.

4.        Accepted Payment Methods:

o   Payments may be made by credit/debit card. An active credit/debit card must be left on file at all times.

5.        Outstanding Balances:

o   If a client has an outstanding balance exceeding $100, services may be placed on hold until payment arrangements are made.

o   Balances over 60 days past due may be sent to collections unless a payment plan is established.

6.        Payment Plans:

o   Clients experiencing financial hardship may request a payment plan, subject to clinic approval.

o   Failure to adhere to an agreed-upon payment plan may result in service suspension.

7.        Refund Policy:

o   Payments for services rendered are non-refundable.

8.        Fee schedule

o Initial Intake Session/ $200/ [Duration: 50 minutes]

o Individual Therapy Session/ $150/ [Duration: 50 minutes]

o Missed Appointment/Late Cancellation (Less than 24 hours notice)/ $100/ Non-refundable

o Sliding Scale Fee/ $80 – $140/ Based on financial need & clinic approval

o Documentation/ Letters/ Forms Completion/ $50/ Per form

o Court Testimony/Legal Requests/ $300 per hour/ Minimum 3-hour charge

Welcome & Purpose

Welcome to Mental Mix Therapy PLLC. This document outlines important information regarding our services, policies, and your rights as a client. Please read carefully and discuss any questions with your therapist before signing.

Nature of Therapy

Psychotherapy involves a collaborative process between therapist and client to address emotional, behavioral, or psychological concerns. While therapy has shown benefits for many people, there are also potential risks, such as experiencing uncomfortable emotions or discussing distressing topics.

Confidentiality & HIPAA

Your information is protected under HIPAA and applicable state laws. Information will not be released without your written consent except in the following situations:

·       Suspected child, elder, or dependent adult abuse

·       If you pose a serious risk of harm to yourself or others

·       If required by court order or other legal obligation

·       As needed for treatment, payment, or healthcare operations

You have the right to request access to your records, receive an accounting of disclosures, and request corrections. For full details, see the Client Confidentiality and HIPAA Policy.

Communication Policy

We communicate via phone, email, and optional secure messaging. Please note:

·       Communication is primarily for scheduling purposes

·       Therapists do not provide crisis support or clinical intervention outside of sessions

·       Responses are typically provided within 24 business hours

In case of emergency, contact 911 or the 988 Suicide & Crisis Lifeline. For full guidelines, refer to the Client Communication Policy.

Emergency & Crisis Protocol

We are an outpatient practice and do not provide emergency mental health services. In the event of a crisis, please:

·       Call 911 or go to the nearest emergency room

·       Contact 988 or your local crisis line

Therapists will assist in safety planning during scheduled sessions if clinically appropriate. See the Emergency and Crisis Protocol for more.

Appointments, Late Cancellations, & No-Shows

Regular attendance is important for progress in therapy. If you must cancel, provide at least 24 hours’ notice. Fees may apply for:

·       Late cancellations: $100

·       No-shows: $100

These fees are not billable to insurance. See the Late Cancellation and No-Show Policy for full details.

Clients may be subject for termination for inconsistent attendance and/ or frequent no-showing or late cancellations.

Financial Policy & Billing

Clients are responsible for all charges not covered by insurance. This includes:

·       Deductibles, copays, and coinsurance

·       Missed appointment fees

·       Out-of-network or denied claims

Payments can be made via credit/debit card. A detailed fee schedule is included in the Clinic Financial Policy.

Telehealth Consent (If Applicable)

If sessions are conducted via Telehealth, please note:

·       You must be located in a state your therapist is licensed in

·       Sessions will be conducted via a secure, HIPAA-compliant platform

·       It is your responsibility to ensure privacy on your end

Client Rights & Responsibilities

You have the right to:

·       Be treated with respect and dignity

·       Ask questions about your treatment

·       Decline or withdraw from treatment at any time

·       Receive referrals if you choose to discontinue therapy

You are responsible for:

·       Attending sessions as scheduled

·       Participating actively in your treatment

·       Communicating openly with your therapist

Purpose:
To ensure timely access to care for all clients and maintain operational efficiency, this policy establishes guidelines for late cancellations and missed appointments.

Policy Statement:
Clients are expected to attend all scheduled appointments. If a client is unable to attend, they must provide advance notice to allow the clinic to offer the appointment slot to another individual in need of services.

Definitions:

·       Late Cancellation: Any appointment canceled with less than 24 hours’ notice.

·       No-Show: A client who fails to attend a scheduled appointment without prior notice or aren’t present at their appointment within 15 minutes of the scheduled appointment start time.

o   Example: If a client is scheduled for 3PM, and they aren’t at their appointment by 3:15PM, this would be considered a no-show. The no-show fee will be charged, and the appointment will have to be rescheduled.

Cancellation and No-Show Guidelines:

1.        Notice Requirement: Clients must cancel or reschedule appointments at least 24 hours in advance.

2.        Late Cancellation Fee: Clients who cancel an appointment with less than 24 hours’ notice may be charged a fee of $100.

3.        No-Show Fee: Clients who fail to attend an appointment without notice may be charged a fee of $100.

4.        Exceptions: Fees may be waived under certain circumstances, such as emergencies or unavoidable situations, at the discretion of the clinic.

5.        Repeated Violations: Repeated late cancellations or no-shows may result in:

o   A requirement for pre-payment before scheduling future appointments.

o   Temporary suspension of services.

o   Termination of services, as determined by the provider.

6.        Insurance Coverage: Most insurance plans do not cover late cancellation or no-show fees. Clients are responsible for these charges.

Procedure for Cancellations:

·       To avoid a late cancellation fee, clients must notify the clinic by texting or calling 313-380-0179 or emailing hayley@mentalmixtherapy.com at least 24 hours before the appointment.

·       If a client repeatedly cancels appointments, a discussion will be held regarding their commitment to treatment and alternative scheduling options.