Policies & Legal Information

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

This document is adapted from the U.S. Department of Health and Human Services' Model Notice of Privacy Practices. Minnesota's legal requirements are in italic text. Please review it carefully and ask any questions you may have before signing.

YOUR RIGHTS

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

Receive an electronic or paper copy of your medical record

You can ask to see or copy an electronic or paper copy of your medical record and other health information we have about you. Ask me how to do this.

I will provide a copy or a summary of your health information within 30 calendar days of your request, unless otherwise permitted by law.

If you ask to see or receive a copy of your record for purposes of reviewing current medical care, I may not charge you a fee. [Minn. Stat. § 144.292 subd. 6]

If you request copies of your patient records of past medical care, or for certain appeals, I may charge you specified fees. [Minn. Stat. § 144.292 subd. 6]

Ask me to correct your medical record

You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this.

I may say "no" to your request, but I'll tell you why in writing within 60 days.

Request for me to contact you confidentially

You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

I will say "yes" to all reasonable requests.

Ask me to limit what I use or share

You can ask me not to use or share certain health information for treatment, payment, or my operations (TPO). I am not required to agree to your request, and I may say "no" if it would affect your care.

If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will say "yes" unless a law requires me to share that information.

Minnesota law requires consent for disclosure of treatment, payment, or operations information. [Minn. Stat. § 144.293 subd. 2]

Get a list of those with whom I've shared information

You can ask for a list (accounting) of the times I've shared your health information for six years prior to the date you ask, who I shared it with, and why.

I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make).

I'll provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within that time.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.

You can also access a copy on my website at Theraspire.com.

File a complaint if you feel your rights are violated

You can complain if you feel I have violated your rights by contacting me using the information on this document.

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

I will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell me your choices about what I share.

If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions.

In these cases, you have both the right and choice to tell me NOT to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

If you are not able to tell me your preference—for example, if you are unconscious—I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, I will never share your information unless you give me written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

Minnesota law also requires consent for most other sharing purposes.

Note: I do not use your information for marketing, nor do I sell your information.

In the case of fundraising: Theraspire does not currently engage in fundraising activities. However, if I were to contact you for fundraising purposes, you can tell me not to contact you again.

MY USES AND DISCLOSURES

How do I typically use or share your health information?

IMPORTANT NOTICE ABOUT REDISCLOSURE: Protected health information that I disclose as permitted by this notice may be redisclosed by the recipient and may no longer be protected by HIPAA once disclosed.

I typically use or share your health information in the following ways:

I need your consent before I disclose protected health information for treatment, payment, and operations purposes, unless the disclosure is to a related entity, or the disclosure is for a medical emergency and I am unable to obtain your consent due to your condition or the nature of the medical emergency. [Minn. Stat. § 144.293, subd. 2 and 5]

Treat you

I can use your health information and share it with other professionals who are treating you only if I have your consent.

I can only release your health records to health care facilities and providers outside of my network without your consent if it is an emergency and you are unable to provide consent due to the nature of the emergency. I may also share your health information with a provider in my network. [Minn. Stat. § 144.293, subd. 2 and 5]

Example: A health professional treating you for an injury asks another provider about your overall health condition.

Run my organization

I can use and share your health information to run my practice, improve your care, and contact you when necessary.

I am required to obtain your consent before I release your health records to other providers for their own health care operations. [Minn. Stat. § 144.293, subd. 2 and 5]

Example: I use health information about you to manage your treatment and services.

Bill for your services

I can use and share your health information to bill and get payment from health plans or other entities only if I obtain your consent. [Minn. Stat. § 144.293, subd. 2 and 5]

Example: I give information about you to your health insurance plan so it will pay for your services.

How else can I use or share your health information?

I am allowed or required to share your information in other ways, usually in ways that contribute to the public good, such as public health and research.

I have to meet many conditions in the law before I can share your information for these purposes. For more information see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

I can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone's health or safety

Do research

Theraspire does not currently engage in research activities.

However, I can use or share your information for health research if you do not object. [Minn. Stat. § 144.295, subd. 1]

Comply with the law

I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that I'm complying with federal privacy law. [Minn. Stat. § 144.293, subd. 2]

Respond to organ and tissue donation requests

I can share health information about you with organ procurement organizations only with your consent. [Minn. Stat. § 525A.14]

Work with a medical examiner or coroner

I can share health information with a coroner and medical examiner when an individual dies.

I need consent to share information with a funeral director. [Minn. Stat. § 390.11, subd. 7(a)]

Address workers' compensation, law enforcement, and other government requests

I can use or share health information about you:

• For workers' compensation claims

• For law enforcement purposes or with a law enforcement official with your consent, unless required by law. [Minn. Stat. § 144.293, subd. 2]

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services with your consent, unless required by law. [Minn. Stat. § 144.293, subd. 2]

Respond to lawsuits and legal actions

I can share health information about you in response to a court or administrative order, or in response to a subpoena.

Other State Law

In Minnesota, I need your consent before I disclose protected health information for treatment, payment, and operations purposes, unless the disclosure is to a related entity, or the disclosure is for a medical emergency and I am unable to obtain your consent. [Minn. Stat. §§ 13.386, 254A.09]

MY RESPONSIBILITIES

I am required by law to maintain the privacy and security of your protected health information.

I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. (45 CFR 164.404 — HIPAA Breach Notification Rule)

I must follow the duties and privacy practices described in this notice and give you a copy of it.

I will not use or share your information other than as described here unless you tell me I can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.

For more information see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

CHANGES TO THE TERMS OF THIS NOTICE

I can change the terms of this notice, and the changes will apply to all information I have about you.

The new notice will be available upon request, in my office, and on my website.

OTHER INFORMATION

Effective Date: November 11, 2025

Privacy Official: Kari Silverberg, MA, LMFT, CHt, EAS-C Theraspire Counseling Services, PLLC 18510 MN-371, Ste. D Brainerd, MN 56401 Theraspire.com 763-355-4675

This notice only applies to Theraspire Counseling Services, PLLC.

STATEMENT OF UNDERSTANDING

I hereby acknowledge that I have read in full the Minnesota Notice of Privacy Practices (HIPAA).

I understand I may view this policy at any time on Theraspire.com, by signing into the Client Portal, or by requesting a copy.

Notice to Clients and Prospective Clients:

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• I will provide you with a Good Faith Estimate in writing within the federally mandated timeframe (typically 1–3 business days) after scheduling your appointment. You can also ask me for a Good Faith Estimate before you schedule an item or service.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

• I recommend that you save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

Effective Date: October 1, 2024

This policy is maintained in compliance with Minnesota Statutes § 62J.806 and § 62J.807. It explains how I communicate with clients about medical debt, the steps I take before referring accounts to collections, and how I identify debt as uncollectible or satisfied.

Communication About Medical Debt

If you have an outstanding balance, I will communicate with you in the following ways:

• Monthly statements: You will receive billing statements showing your current balance, recent charges, and payments received.

• Phone contact: If your balance remains unpaid for 30 days, I may contact you by phone to discuss payment options.

• Email: With your permission, I may send billing reminders to your email address.

• In-person discussion: When appropriate, we may discuss your balance during an appointment.

All communications will be respectful and confidential. I will not contact third parties (such as family members, friends, or employers) about your medical debt.

Referral to Collection Agency or Law Firm

Before referring any account to a collection agency or attorney, I will take the following steps:

• Initial contact: I will make at least one attempt to contact you by phone or mail to discuss your balance and payment options.

• Written notice: If a balance remains unpaid for more than 30 days and no payment arrangement has been made, you will receive written notice at least 30 days before any referral to a collection agency or attorney.

• Notice contents: The written notice will clearly state the amount owed, explain your options for setting up a payment plan, describe how to request financial hardship consideration, and provide information on how to dispute charges if you believe they are incorrect.

• Time to respond: You will have at least 30 days from the date of the written notice to contact me, arrange a payment plan, or dispute the charges before the account is referred for collection.

I do not refer accounts to collection without first making reasonable efforts to work with you directly. If you receive a notice and need more time or have questions, please contact me as soon as possible.

Identifying Debt as Uncollectible or Satisfied

A balance will be marked as uncollectible or satisfied, and all collection activities will end when:

• The balance has been paid in full.

• A settlement agreement has been reached and fulfilled.

• You have been approved for financial hardship assistance and the balance has been reduced or forgiven.

• You have filed for bankruptcy and the debt has been discharged.

• The debt is determined to be uncollectible (for example, you cannot be located, you have passed away with no estate, or collection costs exceed the debt amount).

• The statute of limitations for collection has expired.

When this occurs, you will be notified in writing and all collection activities will cease.

Continuity of Care

I do not deny clinically appropriate or medically necessary care solely because of an outstanding balance. In accordance with Minnesota Statute § 62J.807, I will not refuse to provide medically necessary health treatment or services to you or any member of your family or household because of current or previous outstanding medical debt.

However, if you have an outstanding balance, I may require you to enroll in a payment plan as a condition of providing ongoing services. Any payment plan will be reasonable and will take into account the information you provide about your ability to pay.

Payment Plans and Financial Hardship

I understand that unexpected financial difficulties can arise. If you are unable to pay your balance in full, I encourage you to contact me to discuss payment options.

Payment Plans

I offer payment plans that allow you to pay your balance over time in amounts that work for your budget. Payment plans are tailored to your individual financial situation. To request a payment plan, please contact me by phone or email.

Financial Hardship Consideration

If you are experiencing significant financial hardship, you may request consideration for a balance reduction or adjustment. Please contact me and be prepared to provide information about your financial situation. Each request will be evaluated individually.

How to Contact Me

If you have questions about your bill, need to set up a payment plan, wish to discuss financial hardship, or want to dispute a charge, please contact me.

Policy Availability

You may also request a printed copy at any time by contacting me. This policy may be updated periodically to reflect changes in applicable laws or practices.

Last Updated: October 25, 2025

The contents of this website and all associated pages are provided for informational purposes only and are subject to change without notice. The information contained herein does not constitute therapeutic, legal, or professional advice. Neither the use of this site nor any communication through this site establishes a therapist-client relationship between the user and me. Kari L.M. Silverberg, MA, LMFT, CHt, EAS-C, and Theraspire Counseling Services, PLLC, expressly disclaim all liability for damages of any kind arising out of the use, reference to, or reliance on any information contained within the site. By continuing to use this website, you hereby acknowledge and consent to the provisions of this disclaimer.