Meet the therapist.

Insurances in network with: University of Utah BXBS (HMHI) and EMI

If I am out-of-network with your insurance, I will take full payment at time of service, then I will provide you with a superbill that you can submit to your insurance. Then pending your coverage, you may receive partial to full payment refunds from your insurance company directly. It is your responsibility to verify your out of network benefits, along with confirming your insurance company will accept superbills.

Payment for services are due at the time they are rendered. HSA, cash, and all major credit cards are accepted forms of payment.

You will be provided a super-bill to submit to your insurance company to seek reimbursement directly from them. It is important to verify your out of network benefit with your insurance company.

Essentially, a Superbill is an itemized list of all services provided to a client. The Superbill will also contain additional information about the patient visit including practice information, CPT codes, ICD-10 codes.

If you do not show up for your scheduled therapy appointment, you will be charged a full session ($160) no show fee. If you are 15 minutes late to your appointment, it will be counted as a no show, and a full session ($160) no show fee will be applied.

I understand that things come up and schedules change. If you need to reschedule or cancel your appointment, please do so at least 24 hours before your scheduled appointment time. If you have not notified me at least 24 hours in advance, you will be charged a $160 LATE cancellation fee.

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

Perinatal Wellness LLC (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

YOUR RIGHTS

Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI.

• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.

• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

To amend PHI.

• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.

• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications.

• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared.

• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.

• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared.

• You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice.

• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

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 using the following information:

Perinatal Wellness LLC
4055 S 700 E, STE 204, Millcreek, UT 84107
Betty Flores, LCSW
385-501-3752

• 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.

OUR USES AND DISCLOSURES

1. Routine Uses and Disclosures of PHI

The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

To treat you.

• The Practice can use and share PHI with other professionals who are treating you.

• Example: Your primary care doctor asks about your mental health treatment.

To run the health care operations.

• The Practice can use and share PHI to run the business, improve your care, and contact you.

• Example: The Practice uses PHI to send you appointment reminders if you choose.

To bill for your services.

• The Practice can use and share PHI to bill and get payment from health plans or other entities.

• Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object

The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

• Public health and safety issues (disease prevention, recalls, adverse reactions, abuse/neglect reporting, serious threats).

• Compliance and oversight (HHS investigations, audits, inspections, benefit programs).

• Law and government requests (laws, courts, subpoenas, law enforcement, military/national security, worker’s compensation).

• Other requests (coroners, funeral directors, organ donation, approved research, inmate care, business associates).

3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object

Unless you object, the Practice may disclose PHI:

• To your family, friends, or others if PHI directly relates to that person's involvement in your care.

• If it is in your best interest because you are unable to state your preference.

4. Uses and Disclosures of PHI Based Upon Your Written Authorization

The Practice must obtain your written authorization to use and/or disclose PHI for:

• Marketing

• Sale of PHI

• Psychotherapy notes

You may revoke your authorization at any time by contacting the Practice in writing. The Practice will not use or share PHI other than as described in this Notice unless you give your permission in writing.

OUR RESPONSIBILITIES

• The Practice is required by law to maintain the privacy and security of PHI.

• The Practice must 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 reserves the right to amend this Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice.

• The Practice will inform you if PHI is compromised in a breach.

SOCIAL MEDIA DISCLAIMER

Perinatal Wellness LLC maintains a presence on social media platforms (e.g., Instagram, Facebook, TikTok) to share general educational information and resources related to perinatal mental health. Please note:

• Social media content is not therapy, medical advice, or a substitute for professional care.

• Interactions such as “likes,” comments, direct messages, or follows do not establish a therapist-client relationship.

• For your privacy, please avoid sharing personal health information on any public platform.

• If you are an active or prospective client, communication about your care should occur only through secure, HIPAA-compliant channels (e.g., phone, email, client portal).

• Any engagement with the Practice’s social media is voluntary and not required as part of your care.

Effective Date: August/26/2025