Grafted Counseling and Wellness LLC
Effective Date: August 30, 2026
This Notice describes how medical and mental health information about you may be used and disclosed and how you can obtain access to this information. Please review it carefully.
Grafted Counseling and Wellness LLC is committed to protecting the privacy and confidentiality of your protected health information ("PHI") in accordance with applicable federal and state law.
For questions about this Notice, your privacy rights, or the privacy practices of Grafted Counseling and Wellness LLC, please contact:
Privacy Contact: Charlene Polasky
Email: charlene@graftedcounseling.com
Phone: (216) 438-1567
You have certain rights regarding your health information.
You may request to see or obtain an electronic or paper copy of your medical or mental health record and other health information maintained about you.
We will generally provide a copy or summary of your health information within the time required by law. A reasonable, cost-based fee may be charged when permitted by law.
You may ask us to correct health information about you that you believe is incorrect or incomplete.
We may deny certain requests as permitted by law. If we deny your request, we will explain the reason in writing within the timeframe required by law.
You may ask us to communicate with you in a particular manner or at a particular location.
We will accommodate reasonable requests as required by law.
You may ask us not to use or disclose certain health information for treatment, payment, or healthcare operations.
We are generally not required to agree to all requested restrictions. If we agree to a restriction, we will follow it except when disclosure is necessary for emergency treatment or otherwise permitted or required by law.
Because Grafted Counseling and Wellness LLC is a self-pay practice and does not accept or bill insurance, services are paid directly by the client.
You may request a list, or "accounting," of certain disclosures of your health information made during the six years before the date of your request.
The accounting generally does not include disclosures for treatment, payment, or healthcare operations and certain other disclosures excluded by law.
We will provide one accounting during a 12-month period without charge. A reasonable, cost-based fee may apply to additional requests during the same 12-month period.
You may request a paper copy of this Notice at any time, even if you previously agreed to receive it electronically.
The current Notice is also available on the Grafted Counseling and Wellness LLC website.
If you have given someone medical power of attorney, have a legal guardian, or have another legally authorized personal representative, that person may exercise certain rights and make certain choices regarding your health information as permitted by law.
We will verify the person's legal authority before taking action.
You may file a complaint if you believe your privacy rights have been violated.
Charlene Polasky, Privacy Contact
charlene@graftedcounseling.com
(216) 438-1567
You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.
Grafted Counseling and Wellness LLC will not retaliate against you for filing a complaint or exercising your privacy rights.
For certain health information, you may tell us your preferences about what we share.
Where applicable, you may tell us whether we may:
If you are unable to communicate your preference, such as during an emergency, we may disclose information when we believe disclosure is in your best interest and is permitted by law.
We may also disclose information when necessary to lessen a serious and imminent threat to health or safety, as permitted by law.
Mental health information receives important privacy protections.
Psychotherapy notes, when created and maintained separately from the medical record as defined by HIPAA, receive additional protection. In most circumstances, your written authorization is required before psychotherapy notes may be used or disclosed, except where use or disclosure is specifically permitted or required by law.
Grafted Counseling and Wellness LLC will comply with applicable federal and state laws that provide additional protections for mental health records.
Certain substance use disorder treatment records may receive additional confidentiality protections under federal law, including 42 CFR Part 2.
When Grafted Counseling and Wellness LLC creates, receives, or maintains records protected by 42 CFR Part 2, those records will be used and disclosed in accordance with applicable federal requirements.
Where your consent or authorization is required, your information will not be used or disclosed without the required permission except as otherwise permitted or required by law.
We may use your health information and disclose it to other healthcare professionals involved in your treatment when permitted by law.
For example, information may be shared with another healthcare professional involved in coordinating your care.
We may use and disclose health information as necessary to operate the practice, manage services, improve quality, conduct appropriate administrative activities, and comply with professional and legal requirements.
Grafted Counseling and Wellness LLC is a self-pay-only practice. Insurance is not accepted or billed for services.
We may use health information as reasonably necessary to process your direct payment, maintain financial records, and conduct related administrative activities.
We may use or disclose your health information without your written authorization when permitted or required by applicable law. Depending upon the circumstances, this may include disclosures:
Applicable federal and state confidentiality protections may impose additional limitations on the disclosure of mental health or substance use disorder information.
We will obtain your written authorization before using or disclosing your protected health information when HIPAA or another applicable law requires authorization.
This generally includes most uses or disclosures of psychotherapy notes, marketing involving protected health information, and the sale of protected health information, subject to exceptions provided by law.
If you give us written authorization, you may revoke that authorization in writing at any time. Revocation will not affect actions already taken in reliance upon your authorization.
Grafted Counseling and Wellness LLC is required by law to:
We will not use or disclose your information other than as described in this Notice unless you provide written permission or the use or disclosure is otherwise permitted or required by law.
Grafted Counseling and Wellness LLC may use electronic systems in connection with healthcare services, recordkeeping, communications, scheduling, payment, and telehealth services.
We take reasonable and appropriate administrative, physical, and technical safeguards to protect electronic protected health information as required by applicable law.
Electronic communication may carry privacy and security risks. Clients should use communication methods designated by the practice for confidential or clinical information rather than ordinary website forms or other communication methods not designated for protected health information.
Grafted Counseling and Wellness LLC may change the terms of this Notice and its privacy practices as permitted by law.
Changes may apply to health information we already maintain as well as information received or created in the future.
When this Notice is materially revised, the current version will be made available as required by law and posted on the Grafted Counseling and Wellness LLC website.
For questions about this Notice, requests concerning your health information, requests for a copy of this Notice, or privacy-related concerns or complaints, please contact:
Charlene Polasky, Privacy Contact
charlene@graftedcounseling.com
(216) 438-1567
You may also file a privacy complaint directly with the U.S. Department of Health and Human Services, Office for Civil Rights.
Grafted Counseling and Wellness LLC will not retaliate against you for exercising your privacy rights or filing a complaint.
Grafted Counseling and Wellness LLC
Notice of Privacy Practices
Effective August 30, 2026