NOTICE OF PRIVACY PRACTICES:

PAIN TO PRESENCE PSYCHOTHERAPY LLC

Telehealth Services for clients in the State of Arizona

Effective Date: 05/25/2026 | Last Revised: 05/25/2026

THIS NOTICE DESCRIBES HOW HEALTH 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 Your Health Information

I understand that health information about you and your health care is personal. I am committed to protecting your health information. I create a record of the care and services you receive from me, and 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 Pain to Presence Psychotherapy LLC. It describes the ways I may use and disclose your health information, your rights regarding that information, and my obligations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as well as applicable Arizona law.

I am required by law to:

  • Maintain the privacy and security of your protected health information (PHI).

  • Provide you with this Notice of my legal duties and privacy practices.

  • Follow the terms of the Notice currently in effect.

  • Notify you in the event of a breach of your unsecured PHI.

I may change the terms of this Notice at any time. Changes will apply to all health information I hold about you. The updated Notice will be provided to you at your next appointment and will be available upon request and on my website.

II. How I May Use and Disclose Your Health Information

The following describes the different ways I may use and disclose your health information. Not every possible use or disclosure within each category is listed, but all permitted uses and disclosures fall within one of these categories.

For Treatment, Payment, or Health Care Operations

Federal privacy rules permit health care providers with a direct treatment relationship with you to use or disclose your PHI without written authorization in order to carry out treatment, payment, or health care operations.

Treatment

I may use and disclose your PHI to provide, coordinate, or manage your mental health care. For example, if I consult with another licensed health care provider about your condition, I may share relevant PHI to assist in your diagnosis and treatment.

Disclosures for treatment purposes are not limited to the minimum necessary standard, as health care providers may need access to complete information to provide quality care.

Payment

This practice currently operates on a private-pay basis. If insurance participation changes, clients will be notified.

Health Care Operations

I may use and disclose your PHI for practice administration purposes, such as quality review, professional training, licensing compliance, and other activities necessary to operate this practice effectively.

Lawsuits and Legal Disputes

If you are involved in a lawsuit or legal dispute, I may disclose your health information in response to a court or administrative order. I may also disclose PHI in response to a subpoena, discovery request, or other lawful legal process, but only after efforts have been made to notify you or to obtain a court order protecting the information requested.

III. Uses and Disclosures That Require Your Written Authorization

The following uses and disclosures of your PHI require your written authorization before they may occur:

Psychotherapy Notes

I keep psychotherapy notes as that term is defined in 45 CFR § 164.501. Psychotherapy notes are kept separate from the designated client record. Any use or disclosure of those notes requires your written authorization, unless the use or disclosure is:

  • For my use in treating you.

  • For my use in training or supervising mental health practitioners to improve their clinical skills.

  • For my use in defending myself in legal proceedings initiated by you.

  • For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

  • Required by law, and the use or disclosure is limited to what the law requires.

  • Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

  • Required by a coroner performing duties authorized by law.

  • Required to help avert a serious threat to the health or safety of others.

Marketing Purposes

  • I will not use or disclose your PHI for marketing purposes without your written authorization.

·       Sale of PHI

  • I will not sell your PHI in the regular course of business.

You may revoke any written authorization at any time by submitting a written request to me. Your revocation will take effect upon receipt, except to the extent I have already acted in reliance on the authorization.

IV. Uses and Disclosures That Do Not Require Your Authorization

Subject to certain limitations in the law, I may use or disclose your PHI without your authorization in the following circumstances:

  • When required by state or federal law, and the use or disclosure complies with and is limited to what that law requires.

  • For public health activities, including reporting suspected child abuse, elder abuse, or dependent adult abuse; or preventing or reducing a serious threat to anyone’s health or safety.

  • For health oversight activities, including government audits, investigations, and inspections of health care providers.

  • For judicial and administrative proceedings, including responding to a court or administrative order. Where possible and appropriate, I will seek your authorization before making such disclosures when legally appropriate and practicable.

  • For law enforcement purposes, including reporting crimes occurring on my premises or as otherwise required by law.

  • To coroners or medical examiners, when performing duties authorized by law, such as identifying a deceased person or determining a cause of death.

  • For research purposes, including research that has been approved by an institutional review board, subject to applicable privacy protections.

  • For specialized government functions, including activities related to national security, intelligence operations, military missions, or the safety of individuals in correctional institutions.

  • For workers' compensation purposes. I may disclose your PHI to comply with workers' compensation laws. Where possible, I will seek your authorization first.

  • For appointment reminders and health-related services. I may use your PHI to send appointment reminders or to inform you of treatment alternatives or other healthcare services I offer.

V. Uses and Disclosures That Require You to Have the Opportunity to Object

In certain situations, I may share your PHI with family members, friends, or others involved in your care or payment for your care — but only if you have been given the opportunity to agree or object, and have not objected. In emergency situations, your opportunity to consent may be obtained after the fact.

VI. Your Rights Regarding Your Protected Health Information

You have the following rights with respect to your PHI. To exercise any of these rights, please submit a written request to me using the contact information provided at the end of this Notice.

1.     The Right to Request Limits on Uses and Disclosures

You may ask me to not use or disclose certain PHI for treatment, payment, or healthcare operations purposes. I am not required to agree to your request, and I may decline if I believe doing so would affect your care. However, if you have paid for a service out of pocket in full, you have the right to request that I not disclose that PHI to your health plan for payment or operations purposes, and I am required to honor that request (see Right #2 below).

2.     The Right to Request Restrictions for Out-of-Pocket Services Paid in Full

If you pay for a healthcare service entirely out of pocket, you have the right to request that I not disclose the related PHI to your health plan for payment or operations purposes. I am required to honor this request under 45 CFR § 164.522(a)(1)(vi). This right is particularly relevant if you receive services from me on a private-pay basis, even though you may carry insurance coverage.

3.     The Right to Choose How I Communicate PHI to You

You may request that I contact you in a specific way (e.g., by cell phone only, or at a specific address), and I will honor all reasonable requests.

4.     The Right to See and Get Copies of Your PHI

With the exception of psychotherapy notes, you have the right to inspect and obtain an electronic or paper copy of your health records. I will provide a copy or summary within 30 days of receiving your written request. I may charge a reasonable, cost-based fee for copies.

5.     The Right to an Accounting of Disclosures

You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or healthcare operations; or for which you provided authorization. I will respond within 60 days of receiving your request. The accounting will cover the past six (6) years unless you request a shorter period. The first request in any 12-month period is free; additional requests in the same year may be subject to a reasonable cost-based fee.

6.     The Right to Correct or Update Your PHI

If you believe your PHI contains an error or is incomplete, you may request a correction or amendment. I may deny your request if I determine the record is accurate and complete, and I will explain my reason(s) in writing within 60 days.

7.     The Right to a Copy of This Notice

You have the right to receive a paper or electronic copy of this Notice at any time, even if you previously agreed to receive it electronically. Please contact me to request a copy.

8.     The Right to File a Complaint

If you believe your privacy rights have been violated, you may file a complaint with me directly or with the U.S. Department of Health and Human Services’ Office for Civil Rights. I will not retaliate against you for filing a complaint.

To file a complaint with HHS

VII. Privacy and Security of Electronic Health Information

All client records are maintained in SimplePractice, a HIPAA-compliant electronic health records and practice management platform. A signed Business Associate Agreement (BAA) is in place with SimplePractice and all other third-party vendors that may access, store, or transmit your PHI. This practice takes reasonable and appropriate administrative, technical, and physical safeguards to protect your health information from unauthorized access, use, or disclosure. In the event of a breach of your unsecured PHI, I will notify you in accordance with the HIPAA Breach Notification Rule (45 CFR §§ 164.400–414) within 60 days of discovering the breach.

VIII. Telehealth-Specific Privacy Considerations

Pain to Presence Psychotherapy LLC is a telehealth-only practice. All sessions are conducted via SimplePractice's HIPAA-compliant video platform (exceptions may be made for audio phone sessions when deemed clinically appropriate, and/or necessary, for clients to access care). While every reasonable precaution is taken to protect your privacy during telehealth sessions, you acknowledge that electronic communication carries inherent limitations. You are encouraged to conduct sessions from a private, secure location and to use a secure internet connection. Your PHI transmitted through telehealth platforms is subject to the same privacy protections described in this Notice.

IX. Questions and Contact Information

If you have questions about this Notice, or about your privacy rights, please contact:

Pain to Presence Psychotherapy LLC

Therapist / Owner: Michael Tugendhat, LCSW

Email: (non-urgent only):

michael@paintopresencetherapy.com

Client Portal Link: https://michael-tugendhat.clientsecure.me (portal preferred, and if including any personal or clinical information)

Phone:571-314-6385

Website:https://www.paintopresencetherapy.com

Location: 15804 E. Brittlebush Ln. Fountain Hills, AZ 85268

Acknowledgment of Receipt

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you acknowledge that you have received, read, and had the opportunity to ask questions about this Notice of Privacy Practices. Your signature does not waive any rights described in this Notice. A copy of this Notice is available to you at any time upon request.