Soul Explorations LLC
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective Date: August 18, 2025
I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. 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.
I am required by law to:
Make sure that protected health information (“PHI”) that identifies you is kept private
Give you this notice of my legal duties and privacy practices with respect to health information
Follow the terms of the notice that is currently in effect
I can change the terms of this Notice, and such 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 at https://www.aliveexplorations.com/individual-therapy/
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
For Treatment, Payment, or Health Care Operations: I may use or disclose your PHI without your written authorization to carry out treatment, payment, or health care operations. For example, I may consult with another licensed health care provider about your condition, or use your information to bill your insurance company.
Telehealth Services: I provide services via HIPAA-compliant telehealth platforms to residents of Virginia and Florida who are physically located within these states during sessions.
Insurance and Privacy: When using insurance benefits, your diagnosis, treatment plan, and session notes may be shared with your insurance company. Private pay clients eliminate this risk as no information is shared with insurance companies.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes: I do keep “psychotherapy notes” as defined in 45 CFR § 164.501, and any use or disclosure requires your Authorization unless the use or disclosure is for my use in treating you, training, legal defense, HHS compliance investigations, or required by law.
AI Note-Taking: When consented by you, I may use AI note-taking tools to assist with session documentation. This is optional and requires your explicit consent.
Marketing Purposes: I will not use or disclose your PHI for marketing purposes.
Sale of PHI: I will not sell your PHI in the regular course of my business.
IV. 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:
When disclosure is required by state or federal law
Public health activities, including reporting suspected abuse or preventing serious threats to health or safety
Health oversight activities, including audits and investigations
Judicial and administrative proceedings, including court orders
Law enforcement purposes
Research purposes (with proper safeguards)
Workers’ compensation purposes
Appointment reminders and health-related benefits or services
V. 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 payment for your health care, unless you object. The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOUR RIGHTS WITH RESPECT TO YOUR PHI:
The Right to Request Limits: You can ask me not to use or disclose certain PHI for treatment, payment, or health care operations. I am not required to agree to your request.
The Right to Request Restrictions for Out-of-Pocket Expenses: You have the right to request restrictions on disclosures to health plans if you have paid for services out-of-pocket in full.
The Right to Choose How I Send PHI to You: You can ask me to contact you in a specific way (home or office phone) or send mail to a different address.
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. I will provide you with a copy within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee.
The Right to Get a List of Disclosures: You can request a list of instances where I have disclosed your PHI for purposes other than treatment, payment, or health care operations. I will respond within 60 days.
The Right to Correct or Update Your PHI: If you believe there is a mistake in your PHI, you can request that I correct it. I may say “no” to your request, but I will tell you why in writing within 60 days.
The Right to Get a Paper or Electronic Copy of this Notice: You have the right to get a paper copy of this Notice, even if you have agreed to receive it electronically.
VII. COMPLAINTS:
If you believe your privacy rights have been violated, you can file a complaint with:
Soul Explorations LLC
Andrea Shipley, MA, LPC
804.404.5593
andrea@andreashipley.com
Or with the U.S. Department of Health and Human Services:
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775
www.hhs.gov/ocr/privacy/hipaa/complaints/
I will not retaliate against you for filing a complaint.
VIII. CONTACT INFORMATION:
For questions about this Notice or your privacy rights, contact:
Andrea Shipley, MA, LPC
Virginia LPC License 0701007556 | Florida Out-of-State Telehealth Provider Registration
804.404.5593
andrea@andreashipley.com
https://www.aliveexplorations.com/individual-therapy/
Acknowledgement of Receipt of Privacy Notice
Under HIPAA, you have certain rights regarding the use and disclosure of your protected health information. By signing below, you acknowledge that you have received a copy of this Notice of Privacy Practices.
Client Signature: _________________________ Date: _________