Insurances in network with: HMHI (BCBS/UUHP for University of Utah employees)

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 ($180) no show fee. If you are 10 minutes late to your appointment, it will be counted as a no show, and a full session ($180) 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 48 hours before your scheduled appointment time. If you have not notified me at least 48 hours in advance, you will be charged a $180 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.

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

4055 S 700 E, STE 204
Millcreek, UT 84107
Phone: (385) 501-3752
Email: perinatalwellnessllc@gmail.com
Provider: Betty Flores, LCSW, PMH-C

OUR COMMITMENT TO YOUR PRIVACY

Perinatal Wellness LLC (“the Practice”) is committed to protecting your privacy. We are required by federal and state law to maintain the privacy of your protected health information (“PHI”), provide you with this Notice of Privacy Practices (“Notice”), and explain how we may use and disclose your PHI, your rights regarding that information, and our legal duties.

This Notice applies to all services provided by Perinatal Wellness LLC, whether in person or through telehealth. The Practice provides therapy services in person in Millcreek, Utah, and via telehealth to clients located anywhere in Utah.

YOUR RIGHTS

You have the following rights regarding your PHI. To exercise these rights, please submit a written request to the address listed above.

To inspect and copy PHI

You may request an electronic or paper copy of your PHI. We will provide a copy or summary within 30 days and may charge a reasonable, cost-based fee. We may deny access if disclosure could endanger you or another person’s safety; you may request a review of this decision.

To amend PHI

If you believe your PHI is incorrect or incomplete, you may request an amendment in writing, including your reason for the request. If we deny your request, we will provide a written explanation and allow you to submit a statement of disagreement.

To request confidential communications

You may ask us to contact you in a specific way (e.g., home or office phone, different mailing address). We will agree to reasonable requests.

To limit what is used or shared

You may request that we not use or disclose certain PHI for treatment, payment, or operations. While we are not required to agree, we will comply when possible.
If you pay for a service entirely out of pocket, you can request that information about that service not be shared with your insurer.

To obtain a list of disclosures

You may request an accounting of when and with whom your PHI has been shared (other than for treatment, payment, or operations). One free accounting is available every 12 months; additional requests may incur a reasonable fee.

To receive a copy of this Notice

You may request a paper copy of this Notice at any time, even if you received it electronically.

To choose someone to act for you

If you have given another person medical power of attorney or have a legal guardian, that person can exercise your rights on your behalf.

To file a complaint

If you believe your privacy rights have been violated, you may file a complaint with:

Perinatal Wellness LLC
4055 S 700 E, STE 204, Millcreek, UT 84107
Phone: (385) 501-3752
Email: perinatalwellnessllc@gmail.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/

You will not be retaliated against for filing a complaint.

You may also contact the Utah Division of Professional Licensing (DOPL) if you have concerns about a licensed provider’s conduct: dopl.utah.gov.

OUR USES AND DISCLOSURES

1. Routine Uses and Disclosures

We may use or share PHI for treatment, payment, and health-care operations without your written authorization.

• Treatment: We may share information with other providers involved in your care (e.g., OB-GYNs, psychiatrists, lactation consultants) only with your written consent.

• Operations: We may use PHI to run our business, improve services, and contact you (e.g., appointment reminders, follow-ups).

• Payment: We may use and disclose PHI to bill for services or obtain payment from insurance plans.

2. Other Uses and Disclosures Without Authorization

We may also use or disclose PHI without your authorization in certain legally permitted or required situations, including:

• Public health and safety: Preventing or controlling disease; reporting suspected abuse, neglect, or domestic violence; or averting a serious threat to health or safety.

• Duty to warn/protect: When there is an imminent risk of serious harm to yourself or others.

• Compliance and oversight: For audits, investigations, or inspections by health oversight agencies.

• Legal requirements: In response to court orders, subpoenas, or as otherwise required by law.

• Law enforcement or government requests: Including national security or worker’s-compensation matters.

• Other: Organ donation, coroners, funeral directors, or approved research as allowed by law.

3. Uses and Disclosures with Your Authorization or Opportunity to Object

Unless you object, the Practice may disclose PHI when it is in your best interest and you cannot state your preference (e.g., in emergency situations).

4. Uses and Disclosures Requiring Written Authorization

We must obtain your written authorization for:

• Marketing purposes

• Sale of PHI

• Psychotherapy notes

You may revoke authorization at any time by notifying us in writing.

OUR RESPONSIBILITIES

Perinatal Wellness LLC is required by law to:

• Maintain the privacy and security of your PHI.

• Inform you if your PHI has been compromised in a breach.

• Abide by the terms of this Notice.

• Follow more stringent state or federal laws when applicable.

• Provide updated Notices upon request when changes occur.

Record Retention and Security

All clinical records are securely stored in electronic form through HIPAA-compliant systems (TherapyNotes) and are retained for seven (7) years from the last date of service, or longer if required by law. Records are then destroyed in a secure and confidential manner.

GOOD FAITH ESTIMATE / NO SURPRISES ACT

You have the right to receive a Good Faith Estimate explaining the expected cost of your mental-health services. This estimate will be provided prior to the start of treatment or upon request.

TELEHEALTH NOTICE

If you participate in telehealth services, sessions are conducted through a HIPAA-compliant platform. You must be physically located in Utah during telehealth sessions, as the provider is licensed only in Utah. If you move or travel out of state, therapy services may need to pause or adjust to comply with licensing laws.

SOCIAL MEDIA DISCLAIMER

Perinatal Wellness LLC maintains a presence on social-media platforms (e.g., Instagram, Facebook, TikTok) to share general education about perinatal mental health and related topics.

Please note:

• Content shared online is not therapy or a substitute for mental-health care.

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

• Please avoid posting personal health information publicly.

• All client communication should occur only through secure, HIPAA-compliant channels (e.g., phone, email, TherapyNotes portal).

• Engagement with social media is voluntary and not part of your therapeutic relationship.

ACKNOWLEDGMENT OF RECEIPT

By signing electronically in the client portal, I acknowledge that I have received and reviewed the Notice of Privacy Practices for Perinatal Wellness LLC and understand my rights regarding my health information.

Effective Date: October 22, 2025