Notice of Privacy Practices
Practice Information
Ember & Bloom Therapy LLC
6911 Van Dorn Street
Lincoln, NE 68506
402.789.6178
This notice describes how health information may be used and disclosed and how you can get access to this information. Please review it carefully.
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 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. 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.
The Practice is required by law to maintain the privacy and security of PHI.
The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
The Practice will inform you if PHI is compromised in a breach.
II. How I May Use and Disclose Health Information About You:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a health care provider were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the health care provider in diagnosis and treatment of your condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. Certain Uses and Disclosures Require Your Authorization.
Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising associates to help them improve their clinical skills.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the session notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
Marketing Purposes: As a health care provider, I will not use or disclose your PHI for marketing purposes.
Sale of PHI: As a health care provider, 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 the following reasons:
When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
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 health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the patients who received one form of care versus those who received another form of care for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
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.
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.
Use and Disclosure of Substance Use Disorder Records Subject to 42 CFR Part 2:
(A) If applicable, your substance use disorder (“SUD”) records are protected by federal law under 42 C.F.R. Part 2 (“Part 2”). This law provides extra confidentiality protections and requires a separate patient consent for the use and disclosure of SUD counseling notes. Each disclosure made with patient consent must include a copy of the consent or a clear explanation of the scope of the consent. It must also be accompanied by a written notice containing the language in 42 CFR Part 2.32(a). Disclosure of these records requires your explicit written consent, except in limited circumstances such as:
Medical Emergencies: to the extent necessary to treat you,
Reporting Crimes on Program Premises,
Child Abuse Reporting: In connection with incidents of suspected child abuse or neglect to appropriate state or local authorities, and
Fundraising: We will provide you with an opportunity to decline to receive any fundraising communications prior to making such communications. You may revoke this consent at any time as provided by 45 CFR 164.508(b)(5).
(B) Prohibitions on Use and Disclosure of Part 2 Records: SUD records received from programs subject to Part 2, or testimony relaying the content of such records, shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless based on your written consent, or a court order after notice and an opportunity to be heard is provided to you or the holder of the record, as provided in Part 2. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested SUD record is used or disclosed. If SUD records are disclosed to us or our business associates pursuant to your written consent for treatment, payment, and healthcare operations, we or our business associates may further use and disclose such health information without your written consent to the extent that the HIPAA regulations permit such uses and disclosures, consistent with the other provisions in this Notice regarding PHI. You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above.
The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.
V. Certain Uses and Disclosures Require You to Have the Opportunity to Object:
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.
VI. You Have the Following Rights With Respect to Your PHI:
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 am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
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.
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.
The Right to See and Get Copies of Your PHI: Other than “psychotherapy notes,” 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.
The Right to Get a List of the Disclosures I Have Made: You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. 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. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
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 from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice: You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
To choose someone to act for you: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.
To file a complaint if you feel your rights are violated: You can file a complaint by contacting the Practice. 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/. The Practice will not retaliate against you for filing a complaint. To file a complaint or exercise your rights, contact the practice using the information: Ember & Bloom Therapy LLC, Kaelee Salmans, LIMHP 6911 Van Dorn Street, Ste. 2 Lincoln, NE 68506.
Effective Date of This Notice
2/16/2026
Acknowledgement of Receipt of Privacy Notice
This notice is in compliance with all Nebraska requirements and regulations including but not limited to: This Practice complies with HIPAA, as well as any federal or state law that gives greater privacy protections than HIPAA. In addition to HIPAA, this Practice follows: the Child Protection and Family Safety Act, which restricts records related to allegations of child abuse, Neb. Rev. Stat. § 28-710 to 28-727; the Adult Protective Services Act, which restricts access to records related to allegations of vulnerable adult abuse, Neb. Rev. Stat § 28-438 to 28387; Neb. Rev. Stat. § 83-109, which restricts access to records of individuals in all state institutions; the Health and Human Services Act, which restricts the solicitation, disclosure or use of information related to persons applying for or receiving general assistance, medically handicapped children’s services, medical assistance, assistance to the aged, blind or disabled, aid to dependent children, or social services, Neb. Rev. Stat. § 68-313 & Neb. Rev. Stat. § 68-1209; the Food Stamp Act, which restricts the disclosure of information for recipients of the Supplemental Nutrition Assistance Program, 7 U.S.C. § 2020(e)(8); the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, which provides for greater protections for information related to the Temporary Assistance to Needy Families/ Aid to Dependent Children program, 42 U.S.C. § 602(a)(1)(A)(iv) & 45 CFR § 205.50(a); the Refugee Act of 1980, which restricts information related to individuals of the Refugee Resettlement program to only uses and disclosures related to the administration of the program, 45 CFR § 400.27; Nebraska Dept. of Social Services Manual, which provides for the safeguarding of all information regarding applicants or clients or other persons under any program administered by the Nebraska Department of Social Services, 465 NAC 2-005; and the Social Security Act, which places restrictions on the release of information regarding child support enforcement, 45 CFR § 302.35, 45 CFR § 303.15, 45 CFR § 303.21, 45 CFR § 303.70, & Neb. Rev. Stat § 43-512.06.