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.
Effective date: August 3, 2026
Ethos & Auryn Therapy, operated by SE Therapy, LLC — Shannon Ellis, LCSW, CCTP, Owner P.O. Box 68146, Indianapolis, IN 46268 · 317-643-4622 · shannon@ethosandauryn.com
If you see Shannon through Grow Therapy, this is not the notice that governs that care. Ethos & Auryn is a private-pay practice. Clients who use insurance see Shannon through her Grow Therapy panel, and that care is covered by Grow Therapy’s own privacy practices and notice. This notice covers care provided directly through Ethos & Auryn.
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 mental health care practice.
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.
- Notify you if a breach occurs that may have compromised the privacy or security of your information.
How I may use and disclose health information about you
For treatment, payment, or health care operations
Federal privacy rules allow health care providers who have a direct treatment relationship with the client to use or disclose the client’s personal health information without written authorization, in order to carry out the provider’s own treatment, payment, or health care operations. For example, if I were to consult with another licensed health care provider about your condition, I would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist in the diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard, because providers need access to the full record in order to provide quality care. “Treatment” includes the coordination and management of health care with a third party, consultations between providers, and referrals from one provider to another.
Because Ethos & Auryn is private-pay, payment activity is limited to invoices and receipts — no claim, diagnosis, or treatment record is submitted to an insurer by this practice. If you choose to submit a superbill to your insurer yourself, that information is disclosed by you, not by me.
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 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.
Appointment reminders and treatment alternatives
I may use and disclose your PHI to contact you as a reminder that you have an appointment. I may also use and disclose your PHI to tell you about treatment alternatives or other health care services or benefits that I offer.
Uses and disclosures that 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 requirements of that 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. I am a mandated reporter.
- 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 first.
- For law enforcement purposes, including reporting crimes occurring on my premises.
- To coroners or medical examiners performing duties authorized by law.
- For research purposes, including studying and comparing the mental health of clients who received one form of therapy versus another for the same condition.
- For specialized government functions, including military missions, protective services, intelligence operations, and 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.
Uses and disclosures that always require your written 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:
- For my use in treating you.
- For my use in training or supervising mental health practitioners.
- For my use in defending myself in legal proceedings instituted by you.
- For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
- Required by law, and limited to the requirements of that law.
- Required by law for certain health oversight activities pertaining to the originator of the notes.
- Required by a coroner performing duties authorized by law.
- Required to help avert a serious threat to the health and safety of others.
Marketing
As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI
As a psychotherapist, I will not sell your PHI in the regular course of my business.
Anything else
Any other use or disclosure not described in this notice will be made only with your written authorization. You may revoke an authorization in writing at any time. Revocation does not undo disclosures already made in reliance on it.
Disclosures you have the opportunity to object to
I may provide your PHI to a family member, friend, or other person you indicate is involved in your care or in payment for your care, unless you object in whole or in part. In an emergency, the opportunity to object may be offered retroactively.
Your rights
Request limits on uses and disclosures. You may ask me not to use or disclose certain PHI for treatment, payment, or health care operations. I am not required to agree, and I may say no if I believe it would affect your care.
Request restrictions for services paid out of pocket in full. You have the right to request that I not disclose PHI to a health plan when the information pertains solely to a service you have paid for out of pocket in full.
Choose how I contact you. You may ask me to contact you a specific way — a particular phone number, or mail to a different address — and I will agree to all reasonable requests.
See and get copies of your PHI. Other than psychotherapy notes, you have the right to an electronic or paper copy of your record and other information I hold about you. I will provide it, or a summary if you agree to one, within 30 days of your written request, and I may charge a reasonable cost-based fee.
Get a list of disclosures I have made. You may request a list of instances where I disclosed your PHI for purposes other than treatment, payment, or operations, or beyond what you authorized. I will respond within 60 days. The list covers the last six years unless you ask for a shorter period, at no charge for the first request in a year.
Correct or update your PHI. If you believe something is wrong or missing, you may ask me to correct or add to it. I may say no, but I will tell you why in writing within 60 days.
Get a paper or electronic copy of this notice. You have the right to a paper copy, and the right to a copy by email. Even if you agreed to receive it by email, you may still request paper.
Choose someone to act for you. A person with medical power of attorney or a legal guardian may exercise these rights on your behalf.
Be notified of a breach. I will notify you if a breach occurs that may have compromised the privacy or security of your information.
Complain without retaliation. See below.
State law may give you more protection
Where Indiana, Illinois, or Michigan law affords mental health information greater protection than HIPAA, the more protective standard applies. Because this practice is telehealth-only and licensed in all three states, the law of the state you are physically located in during sessions governs those additional protections.
Where your information lives
Clinical records, scheduling, intake paperwork, and secure messaging are maintained in SimplePractice, an electronic health record vendor operating under a HIPAA business associate agreement with this practice.
The public website at ethosandauryn.com is separate and holds no protected health information. It has no forms, no logins, and no way to submit information about yourself.
Email and text are not secure channels. Please do not send clinical detail to my email address. Use the secure portal for anything about your care.
Complaints
If you believe your privacy rights have been violated, tell me directly, in writing, at the address above. I would rather hear it and fix it.
You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at 200 Independence Avenue SW, Washington DC 20201, by calling 1-877-696-6775, or at hhs.gov/ocr/privacy/hipaa/complaints.
You will not be retaliated against for filing a complaint. Not by me, and not in any way that affects your care.
Changes to this notice
I can change the terms of this notice, and any change applies to information I already hold as well as information I receive in the future. The current version is always available on request and posted on this page with its effective date.
Contact
Shannon Ellis, LCSW, CCTP — Privacy Officer Ethos & Auryn Therapy P.O. Box 68146, Indianapolis, IN 46268 shannon@ethosandauryn.com 317-643-4622