Practice Name: Colibri Counseling Services, LLC
Privacy Contact: Ruth Chapman, LCSW/OWNER
Phone: 918-212-8940
Email: hello@colibricounselingok.com
Address: 2417 E. 53rd St. Suite 101 Tulsa, OK 74105
 
YOUR HEALTH INFORMATION

When you receive counseling services from Colibri Counseling Services, we create and maintain records related to your care. These records may contain information about your mental health, treatment, diagnosis, medications, personal history, payment for services, and other information related to your care.

We are committed to protecting the privacy and security of your protected health information (PHI) and will only use or disclose your information as permitted by law and as described in this notice.
 
YOUR RIGHTS

You have the following rights regarding your health information:

1. Get a copy of your records

2. You may request to inspect or obtain a paper or electronic copy of your health information, subject to certain legal limitations.

3. Ask us to correct your records

4. You may request that we correct information about you that you believe is incorrect or incomplete. We may deny your request in certain circumstances, but we will provide you with a written explanation if we do.

5. Request confidential communications

6. You may ask us to contact you in a specific way or at a specific location. For example, you may request that we contact you only by email, phone, or through a particular mailing address. We will accommodate reasonable requests.

7. Ask us to limit what we use or share

8. You may ask us not to use or disclose certain health information for treatment, payment, or health care operations. We are not required to agree to every request.

9. If you pay for a service or health care item completely out of pocket, you may request that we not disclose information about that service to your health insurance plan for payment or health care operations, unless disclosure is required by law.

10. Request a record of disclosures

11. You may request a list of certain disclosures we have made of your health information during the previous six years. Some disclosures are not required to be included in this list, including certain disclosures related to treatment, payment, and health care operations.

12. Receive a copy of this notice

13. You may request a paper copy of this notice at any time, even if you have agreed to receive it electronically.

14. Choose someone to act for you

If you have given someone legal authority to act on your behalf, such as through a medical power of attorney or legal guardianship, that person may exercise your privacy rights on your behalf, subject to applicable law.

15. File a complaint

If you believe your privacy rights have been violated, you may file a complaint with Colibri Counseling Services or with the U.S. Department of Health and Human Services Office for Civil Rights.

You will not be retaliated against for filing a complaint.

 
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

We may use or disclose your health information without your written authorization when permitted or required by law, including for the following purposes:

1. Treatment

2. We may use or share your health information with other health care professionals involved in your treatment when appropriate.

For example, we may communicate with another health care provider involved in your care when necessary to coordinate treatment.

3. Payment

We may use and disclose your health information to obtain payment for services.

For example, if you use health insurance, we may provide information to your insurance company so that it can process and pay a claim.

Health Care Operations

4. We may use and disclose your health information as necessary to operate our practice, improve the quality of care, coordinate services, and perform other activities permitted by law.

5. When Required by Law

6. We may disclose your health information when required to do so by federal, state, or local law.

7. Public Health and Safety

8. We may disclose information when permitted by law for certain public health and safety purposes, including reporting certain diseases, suspected abuse or neglect, or preventing or reducing a serious threat to the health or safety of a person or the public.

9. Legal Proceedings and Law Enforcement

We may disclose health information in response to certain legal proceedings, law enforcement requests, court orders, subpoenas, or other lawful requests when permitted or required by law.

10. Workers' Compensation

We may disclose information as necessary to comply with workers' compensation laws.

11. Other Permitted Disclosures

We may disclose information for other purposes permitted by HIPAA and applicable law, including certain activities involving medical examiners, coroners, organ and tissue donation, and disaster relief.

 
USES AND DISCLOSURES THAT REQUIRE YOUR WRITTEN AUTHORIZATION

Certain uses and disclosures of your health information require your written authorization.

Generally, we will obtain your written authorization before:

• Using or disclosing your information for purposes not otherwise permitted by law;

• Using your information for certain marketing purposes; or

• Selling your health information.

If you provide written authorization, you may revoke that authorization in writing at any time, except to the extent that we have already relied on it.

 
MENTAL HEALTH INFORMATION

Because counseling records may contain particularly sensitive information, we take reasonable steps to protect the confidentiality of your mental health information.

Some information contained in mental health records may be subject to additional protections under federal or state law. We will comply with any applicable additional legal requirements.
 
SUBSTANCE USE DISORDER RECORDS

If we maintain substance use disorder records that are protected under 42 CFR Part 2, those records receive additional federal privacy protections.

As required by applicable law, we will not use or disclose Part 2-protected records except as permitted by Part 2, HIPAA, and other applicable law.

To the extent applicable, Part 2-protected records may not be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding against you without your written consent or a court order and subpoena, as required by federal law.
 
YOUR CHOICES

For certain situations, you may have the opportunity to tell us whether you would like us to share information with family members, friends, or other individuals involved in your care.

You may also request that we communicate with you through a particular method or at a particular location.

We will make reasonable efforts to honor your preferences when required or permitted by law. In the event you are wanting your information shared with a third party a Release of Information will be required prior to the disclosure. 

 
OUR RESPONSIBILITIES

We are required by law to:

• Maintain the privacy and security of your protected health information;

• Provide you with this notice describing our legal duties and privacy practices;

• Follow the terms of the notice currently in effect;

• Notify you promptly if a breach occurs that may have compromised the privacy or security of your health information; and

• Follow applicable federal and state privacy laws.

We will not use or disclose your health information in ways other than those described in this notice unless you provide written authorization or the disclosure is otherwise permitted or required by law.

 
CHANGES TO THIS NOTICE

We reserve the right to change this Notice of Privacy Practices.

If we make a material change to our privacy practices, we will update this notice. The revised notice will be available on our website and upon request.

The revised notice will apply to all health information we maintain about you as permitted by law.
 
QUESTIONS OR COMPLAINTS

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

Colibri Counseling Services
Privacy Contact: Ruth Chapman, LCSW/OWNER
Phone: (918)212-8940
Email: hello@colibricounselingok.com
Address: 2417 E. 53rd St. Suite 101 Tulsa, OK 74105

You may also file a complaint with the:

U.S. Department of Health and Human Services
Office for Civil Rights

You may submit a complaint without fear of retaliation.

Information about filing a complaint is available through the U.S. Department of Health and Human Services Office for Civil Rights.
 
ACKNOWLEDGMENT

You will be asked to acknowledge that you received this Notice of Privacy Practices. Your acknowledgment does not mean that you have authorized any additional use or disclosure of your health information.

You have the right to receive a copy of this notice whether or not you sign an acknowledgment.

Effective Date: 09/14/2026