Notice of Privacy Practices
Buffalo Run Psychological Services, PLLC
801-214-8493
NOTICE OF PRIVACY PRACTICES
Effective Date: 03/31/2026
THIS NOTICE DESCRIBES HOW MEDICAL AND MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information.
1. My Legal Duty to Protect Your Protected Health Information (PHI)
I am required by federal and Utah law to maintain the privacy of your protected health information (PHI) and to provide you with this Notice explaining my legal duties and privacy practices. PHI includes information that identifies you and relates to your past, present, or future physical or mental health condition and related health care services. I am required to abide by the terms of this Notice currently in effect and to notify you in the event of a breach of unsecured PHI. I reserve the right to change the terms of this Notice at any time. Any revisions will apply to all PHI I maintain and will be available upon request and in my office.
2. How I May Use and Disclose Your PHI
Treatment, Payment, and Health Care Operations
Under the Health Insurance Portability and Accountability Act (HIPAA), I may use and disclose your PHI without your written authorization for purposes of treatment, payment, and health care operations. For treatment purposes, I may use your information to provide, coordinate, or manage your mental health care, including consulting with other licensed health care providers. For payment purposes, I may use and disclose your information to bill and collect payment from you, your insurance company, or another responsible third party. For health care operations, I may use your information for administrative, legal, quality assurance, and practice management activities necessary to operate my practice.
Uses and Disclosures Requiring Your Written Authorization
Any other use or disclosure of your PHI will generally require your written authorization. This includes most disclosures outside treatment, payment, and health care operations. You may revoke your authorization at any time in writing, except to the extent that I have already acted in reliance on it. I do not use or disclose PHI for marketing purposes, nor do I sell PHI. I may, only with your consent, provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
3. Psychotherapy Notes
I maintain psychotherapy notes as defined by HIPAA regulations. These notes are kept separate from your general medical record and receive special protection under federal law. Psychotherapy notes will not be disclosed without your written authorization except for my own use in treating you, for supervision or training purposes, to defend myself in legal proceedings initiated by you, as required by law, for health oversight activities, to avert a serious and imminent threat to health or safety, or as otherwise permitted under HIPAA regulations.
4. Uses and Disclosures Required or Permitted by Law
There are circumstances under federal and Utah law in which I may or must disclose your PHI without your authorization.
Under Utah law, I am required to report suspected child abuse or neglect and suspected abuse, neglect, or exploitation of vulnerable adults to appropriate authorities. If I believe you present a serious and imminent threat of harm to yourself or to an identifiable other person, I may disclose relevant information to appropriate individuals or authorities in order to protect health or safety. I may disclose PHI in response to a court order or other lawful process. When responding to subpoenas, I will attempt to notify you or obtain a qualified protective order unless legally prohibited from doing so.
I may also disclose information for public health activities, health oversight activities (such as audits or investigations), certain law enforcement purposes, workers’ compensation claims, or other specialized government functions as required or permitted by law.
5. Disclosures Where You Have the Opportunity to Object
Unless you object, I may disclose limited information to family members, close friends, or other persons involved in your care or payment for your care, when appropriate or necessary. You have the right to object to such disclosures.
6. Your Rights Regarding Your PHI
You have several important rights regarding your PHI.
You have the right to request restrictions on certain uses and disclosures of your PHI.
You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care. While I am not required to agree to most requested restrictions, I must agree to restrict disclosure to a health plan for payment or health care operations purposes if the disclosure relates solely to a service that you have paid for in full out of pocket.
You have the right to request confidential communications, such as asking that I contact you at a specific phone number, address, or by a particular method. I will accommodate all reasonable requests.
You have the right to inspect and obtain a copy of your medical record and other PHI maintained in a designated record set, except for psychotherapy notes and certain other limited categories of information. I will respond to written requests within 30 days and may charge a reasonable, cost-based fee for copies.
You have the right to request that I amend your PHI if you believe it is inaccurate or incomplete. I may deny your request under certain circumstances but will provide a written explanation within 60 days.
You have the right to receive an accounting of certain disclosures of your PHI made in the previous six years, excluding disclosures for treatment, payment, health care operations, and certain other exceptions.
You have the right to receive a paper or electronic copy of this Notice at any time.
7. Complaints
If you believe your privacy rights have been violated, you may file a complaint with:
Buffalo Run Psychological Services, PLLC
Privacy officer: Dr. Hannah Muetzelfeld
801-214-8493
You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. You will not be retaliated against for filing a complaint.
8. Contact Information
If you have any questions about this Notice or your privacy rights, please contact:
Hannah Muetzelfeld, PhD, License # 11900527-2501
Buffalo Run Psychological Services, PLLC
801 214 8493
Acknowledgement of Receipt of Privacy Notice
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.