Notice of Privacy Practices 


I am legally required to protect the privacy of your PHI, which includes information that can be used to identify you that I’ve created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of this health care. I must provide you with this Notice about my privacy practices, and such Notice must explain how, when, and why I will “use” and “disclose” your PHI. A “use” of PHI occurs when I share, examine, utilize, apply, or analyze such information within my practice; PHI is “disclosed” when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of my practice. With some exceptions, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. And, I am legally required to follow the privacy practices described in this Notice. I must notify you if a breach of your unsecured PHI occurs.

However, I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI on file with me already. Before I make any important changes to my policies, I will promptly change this Notice and post on my website. You can also request a copy of this Notice from me, or from my website, which is located at

I will use and disclose your PHI only with your written authorization.. It is your right to revoke such Authorization at any time by giving me written notice of your revocation.


I will use and disclose your PHI for many different reasons. For some of these uses or disclosures, I will need your prior authorization; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category.

  1. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Written Consent. I can use and disclose your PHI without your Authorization for the following reasons:
  1. For your treatment. I can use and disclose your PHI to treat you, which may include disclosing your PHI to another health care professional. For example, if you are being treated by a physician or a psychiatrist, psychologists, and other licensed health care providers who provide you with health care services or are involved in your care. I can disclose your PHI to him or her to help coordinate your care, although my preference is for you to give me Authorization to do so.
  2. To obtain payment for your treatment. I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company to get paid for the health care services that I have provided to you. I may also provide your PHI to my business associates, such as billing companies, claims. processing companies, and others that process my health care claims. although my preference is for you to give me Authorization to do so. 
  3. For health care operations. I can disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. I may also provide your PHI to our accountants, attorneys, consultants, and others to make sure I’m com-plying with applicable laws.
  4. Other disclosures. I may also disclose your PHI to others with-out your consent in certain situations. For example, your consent isn’t required if you need emergency treatment, as long as I try to get your consent after treatment is rendered, or if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so.

 B. Certain Uses and Disclosures Do Not Require Your Authorization. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

  1. When disclosure is required by federal, state or Local law; judicial or administrative proceedings; or, law enforcement. For example, I may make a disclosure to applicable officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding. For judicial and administrative proceedings, including responding to a court or administrative order, including reporting crimes occurring on my premises, Although my preference is to obtain an Authorization from you before doing so.
  2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety. For example, I may have to report information about you to the county coroner or medical examiners, when such individuals are performing duties authorized by law.
  3. For health oversight activities, including audits and investigations. For example, I may have to provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization.
  4. For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research.
  5. For Specialized government functions. I may disclose PHI by  ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter- intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
  6. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
  7. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

Marketing. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

Psychotherapy Notes: I do not keep “psychotherapy notes” as that term is defined in 45 CFR§ 164.501. I maintain a record of your treatment and you may request a copy of such record at any time, or you may request that I prepare a summary of your treatment.

There may be reasonable, cost-based fees involved with copying the record or preparing a summary.

C. Certain Uses and Disclosures Require You to Have the Opportunity to Object.

  1. Disclosures to family, friends, or others. I may 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.

D.  Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in sections III A,   B, and C above, I will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I haven’t taken any action in reliance on such authorization) of your PHI by me.

IV.  YOUR RIGHTS YOUR REGARDING YOUR PHI You have the following rights with respect to your PHI:

  1. The Right to Request Limits on 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 will consider your request, but I am not legally required to accept it. If I accept your request, I will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that I am legally required or allowed to make.
  2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
  3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
  4. The Right to See and Get Copies of Your PHI. You have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so. I may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance.
  5. The Right to Get a List of the Disclosures I Have Made. You have the right to get a list of instances in which I have disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment, or health care operations, directly to you, or to your family. The list also won’t include uses and disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before October 30, 2023. 

I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at a  reasonable cost based fee. 

  1. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. I will respond within 60 days of receiving your request to correct or update your PHI. I may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by me, (iii) not allowed to be disclosed, or (iv) not part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don’t file one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If I approve your request, I will make the change to your PHI, tell you that I have done it, and tell others that need to know about the change to your PHI.
  2. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by email. And, even if you have agreed to receive this Notice via email, you also have the right to request a paper copy of it.


B.A.R.E. Holistic and wellness therapy, Inc., is required by law to notify you following the discovery that there has been a breach of your unsecured PHI, unless B.A.R.E. Holistic and wellness therapy, Inc., reasonably determines, after investigating the situation and assessing the risks presented, that there is a low probability that the privacy or security of your PHI has been compromised. You will be notified in a timely manner, no later than sixty (60) days after discovery of the breach, unless state law requires notification sooner.

HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES If you think I may have violated your privacy rights, or you disagree with a decision I made about access to your PHI, you may file a complaint with me, as the Privacy Officer for my practice, and my address, email, and phone number are: 

Jannie Martinez, LMFT 121121

12440 Firestone Blvd, suite 105, 

Norwalk, 90650

(562) 661-7455.

[email protected]

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

1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;

2. Calling 1-877-696-6775; or,

  3. Visiting

I will not retaliate against you if you file a complaint about my privacy practices.

EFFECTIVE DATE OF THIS NOTICE This notice went into effect on October 30, 2023.