EFFECTIVE DATE OF THIS NOTICE: This notice went into effect on 9/12/2026.

 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 

My Commitment to your Privacy

I understand that information about your mental health and treatment is personal and sensitive. I am committed to protecting the privacy of your protected health information (PHI) and your mental health records and communications.

As a licensed clinical social worker, I am required by law to maintain the privacy of your PHI, provide you with this Notice of Privacy Practices, and follow the privacy practices described in this Notice while it is in effect.

This Notice explains how I may use and disclose your PHI, your rights regarding your health information, and how you can exercise those rights.

Illinois Privacy Protections

Illinois law provides additional confidentiality protections for mental health records and communications. I will comply with applicable federal and Illinois privacy and confidentiality requirements. When applicable law provides greater protection for your information, I will follow the more protective requirement.

How I May Use and Disclose Your Health Information

I may use or disclose your PHI without your written authorization in the circumstances permitted or required by law, including the following:

1. For Treatment:
I may use or disclose your PHI to provide, coordinate, or manage your mental health treatment. This may include consultation with another health care provider involved in your care or making referrals when permitted by law.

2. For Payment:
I may use or disclose your PHI as necessary to obtain payment for services. This may include providing information to your health insurance plan or other payer for purposes such as determining eligibility, obtaining authorization, processing claims, or receiving payment.

3. For Health Care Operations:
I may use or disclose your PHI for certain health care operations, such as quality assessment, administrative activities, compliance activities, or other activities permitted by law.

Legal Proceedings

I may disclose your PHI in response to a court order or other lawful process when permitted or required by applicable law. I will make reasonable efforts to protect the confidentiality of your information to the extent permitted by law.

Psychotherapy Notes

Psychotherapy notes are notes maintained separately from the medical record that document or analyze the contents of counseling conversations and are intended primarily for my own use in providing treatment. Psychotherapy notes receive special protection under federal law and generally require your written authorization before they may be used or disclosed, except in limited circumstances permitted by law. Psychotherapy notes are separate from progress notes and other records maintained as part of your medical record.

 

Marketing

Under no circumstances will I use or disclose your protected health information for marketing. I will never sell your protected health information. 

Uses and Disclosures Permitted or Required by Law

Subject to applicable legal requirements and limitations, I may use or disclose your PHI without your written authorization in circumstances including:

• When disclosure is required by federal or Illinois law

• To report suspected abuse, neglect, or exploitation when required or permitted by law

• To prevent or reduce a serious threat to health or safety when permitted or required by law

• For certain audits, investigations, or oversight activities

• In response to a court order or other lawful process when permitted or required by law

• To facilitate payment for services or use of your health insurance benefits

• To contact you about appointments, scheduling, billing, or other practice-related matters

• To individuals involved in your care or payment for your care, when permitted by law and unless you object

​​

Individuals Involved in Your Care or Payment

Unless you object, I may disclose limited information to a family member, close friend, or another person you identify as being involved in your care or payment for your care, when permitted by law. I will limit the information disclosed to what is reasonably necessary for the purpose.

Your Rights

 

Restricting Disclosure

• You may request that I withhold certain protected health information for treatment, payment, or health care operations purposes. I am not legally required to agree to your request if I believe it would affect your health care. 

• You may request that I withhold protected health information to your health plans for payment or health care operations purposes if it pertains solely to a service that you paid for out-of-pocket in full. 

 

Electronic Communications

• I may communicate with you electronically for scheduling, billing, administrative matters, or other purposes when permitted by law.

• You may request electronic communication or provide an email address or phone number for communication. Electronic communication, including email and text messaging, carries privacy and security risks, and cannot be guaranteed to be completely secure.

• Although I will take reasonable precautions to protect your information, I cannot guarantee the security of information transmitted electronically. When possible, I will limit sensitive clinical information communicated through ordinary email or text messaging.

• If you have concerns about electronic communication, you may request another method of communication.

Right to Receive a Copy of This Notice

• You have the right to receive a paper or electronic copy of this Notice at any time. The most current version will also be made available on my website.

• You have the right to request an electronic or paper copy of any part of your medical record. 

• My psychotherapy notes are not part of the medical record and you have no legal right to view them.

• You generally have the right to inspect or obtain a copy of your health information maintained as part of your designated record set, subject to applicable legal limitations.

• You may request your records in paper or electronic form. I will respond to your request within the time required by applicable law.

  • Certain information may be excluded from your right of access, including psychotherapy notes maintained separately from your medical record and information otherwise excluded by law.

• You have the right to request a list of my disclosures of your protected health information within the past six years. I will respond to your request for an accounting of disclosures within sixty days of receiving your written and signed request. I may charge a reasonable fee set by state law for doing so.

​​

Breach Notification

I am required by law to notify you if a breach of unsecured protected health information occurs that requires notification under applicable law.

 

Right to Correct or Update Your protected health information

• If you believe there is an error in your protected health information or that I am missing an important piece of information, you have the right to request a correction. I may say no but will explain why in writing within sixty days of receiving your request.

 

Questions or Privacy Complaints

If you have questions about this Notice or believe your privacy rights have been violated, please contact:

Carly Murillo, LCSW        Resilient Bloom Therapy        Phone: 815-556-2827
Email: carly@resilientbloomtherapy.com

​

You may also contact the U.S. Department of Health and Human Services, Office for Civil Rights:

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
HHS OCR Complaint Portal​​​​