Bend Mental Wellness, LLC
Notice of Privacy Practices
BEND MENTAL WELLNESS, LLC
64682 Cook Ave #1, Bend, OR 97703
Phone: (541) 357-7686 | Email: ok@bendmentalwellness.com
Website: www.bendmentalwellness.com
NOTICE OF PRIVACY PRACTICES
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.
You may have additional rights under Oregon state law (including ORS 179.505) and federal
law (including HIPAA). If you have questions about your rights to health care information, you
may contact this practice or seek legal counsel from an attorney licensed in Oregon.
Effective Date
This Notice went into effect on January 1, 2026.
I. Our Commitment to Protecting Your Health Information
We understand that your health information is personal and we are committed to protecting it.
We create a record of the care and services you receive from us. We need this record to
provide you with quality care and to comply with certain legal requirements. This Notice applies
to all records of your care generated or maintained by Bend Mental Wellness, LLC, whether
created by your individual clinician or by practice staff.
We are required by law to:
• Ensure that protected health information (“PHI”) that identifies you is kept private;
• Provide you with this Notice of our legal duties and privacy practices with respect to your
health information;
• Follow the terms of the Notice currently in effect; and
• Notify you if we are unable to agree to a requested restriction on how your information is
used or disclosed.
We reserve the right to change the terms of this Notice, and any changes will apply to all
information we have about you. The revised Notice will be available upon request, in our office,
and on our website.
II. How We May Use and Disclose Your Health Information
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A. For Treatment, Payment, or Health Care Operations
Federal privacy rules allow health care providers who have a direct treatment relationship with
you to use or disclose your personal health information, without your written authorization, to
carry out treatment, payment, or health care operations.
• Treatment: We may use your information to provide, coordinate, or manage your health
care and related services. For example, if one of our clinicians consults with another
licensed health care provider about your condition, we are permitted to use and disclose
your PHI to assist in your diagnosis and treatment. Because therapists and other health
care providers need access to complete information to provide quality care, disclosures
for treatment purposes are not limited to the “minimum necessary” standard.
• Payment: We may use and disclose your PHI to bill and collect payment for services,
including submitting claims to your health insurance plan, verifying insurance eligibility,
and communicating with insurance companies regarding coverage, prior authorizations,
and claim disputes.
• Health Care Operations: We may use and disclose your PHI for practice operations,
including quality assessment, staff training and supervision, compliance activities,
business planning, auditing, and sending you appointment reminders.
B. Clinical Supervision and Training
Bend Mental Wellness engages independent clinicians who are working toward full licensure
under clinical supervision, as required by the Oregon Board of Licensed Professional
Counselors and Therapists (OBLPCT). Your PHI may be used during supervision sessions to
ensure quality care and to meet Oregon licensure supervision requirements. Your clinician’s
supervisor has access to clinical information as necessary for clinical oversight, quality
assurance, and compliance with Oregon law.
C. Lawsuits and Disputes
If you are involved in a lawsuit, we may disclose health information in response to a court or
administrative order. We 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 notify you about the request or to obtain an order protecting the
information requested.
III. Uses and Disclosures Requiring Your Written
Authorization
A. Psychotherapy Notes
We maintain “psychotherapy notes” as defined in 45 CFR § 164.501 and ORS 179.505. These
notes are kept separately from your general clinical record. Any use or disclosure of
psychotherapy notes requires your written authorization, except when the use or disclosure is:
• By your treating clinician, for your treatment;
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• For training or supervising mental health practitioners to improve their skills in
counseling or therapy;
• To defend ourselves in legal proceedings you initiate;
• For the Secretary of HHS to investigate our HIPAA compliance;
• Required by law and limited to the requirements of such law;
• For certain health oversight activities pertaining to the originator of the notes;
• Required by a coroner performing legally authorized duties; or
• To help avert a serious threat to health and safety.
B. Marketing
We will not use or disclose your PHI for marketing purposes without your prior written
authorization. If we request a review or testimonial from you and plan to share it publicly, we will
provide you with a HIPAA authorization form. You may revoke this authorization at any time by
submitting a written request. Please note that once a review has been published online, we
cannot guarantee that third parties who may have copied it will also remove it.
C. Sale of PHI
We will not sell your PHI under any circumstances.
D. Other Uses and Disclosures
Any uses and disclosures of your PHI not described in this Notice will be made only with your
written authorization. You may revoke any written authorization you provide to us at any time by
submitting a written request, except to the extent that we have already taken action in reliance
on your authorization.
IV. Uses and Disclosures That Do Not Require Your
Authorization
Subject to certain limitations in the law, we may use and disclose your PHI without your
authorization for the following purposes. We must meet the applicable legal conditions before
sharing your information:
• Appointment reminders and health-related services: We may contact you to remind
you of appointments or to tell you about treatment alternatives or other health care
services we offer.
• As required by law: When disclosure is required by federal or Oregon state law, and
the use or disclosure complies with and is limited to the relevant requirements of such
law.
• Public health activities: Including reporting suspected child abuse or neglect (as
required of mandatory reporters under ORS 419B.010), suspected elder or dependent
adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
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• Health oversight activities: Including audits, investigations, and licensure-related
inspections by the Oregon Health Authority or the Oregon Board of Licensed
Professional Counselors and Therapists (OBLPCT).
• Judicial and administrative proceedings: Including responding to a court or
administrative order, or a subpoena or other lawful process. Our preference is to obtain
your authorization before doing so, where permitted.
• Law enforcement purposes: Including reporting crimes occurring on our premises.
• Serious threats to health or safety: If we believe in good faith that disclosure is
necessary to prevent or lessen a serious and imminent threat to the health or safety of a
person or the public, consistent with applicable law and standards of ethical conduct
(including Oregon’s duty-to-warn provisions).
• Coroners and medical examiners: When performing duties authorized by law.
• Research: When approved by an Institutional Review Board or privacy board, subject to
applicable state and federal law.
• Specialized government functions: Including military and veteran activities, national
security and intelligence activities, and protective services for government officials.
• Workers’ compensation: As necessary to comply with Oregon workers’ compensation
laws, although our preference is to obtain your authorization first.
V. Disclosures Where You Have an Opportunity to Object
You have the right to tell us whether we may share your PHI with a family member, friend, or
other person involved in your care or the payment for your care. If you are unable to
communicate your preference (for example, in an emergency), we may use our professional
judgment to determine whether disclosure is in your best interest. The opportunity to consent
may be obtained retroactively in emergency situations.
VI. Oregon-Specific Protections
A. Confidentiality of Mental Health Records (ORS 179.505)
Under Oregon law, mental health records maintained by this practice are confidential and may
not be disclosed except as specifically permitted by ORS 179.505 or other applicable Oregon or
federal law. Oregon law provides additional protections for mental health records beyond those
required by federal HIPAA regulations. Where Oregon law is more protective than HIPAA, we
follow the stricter Oregon standard.
B. Minors’ Right to Consent to Treatment (ORS 109.675)
Under Oregon law, a minor who is 14 years of age or older may obtain outpatient diagnosis or
treatment for a mental or emotional disorder or chemical dependency without parental
knowledge or consent. However, the treating clinician is expected to involve the minor’s parents
or legal guardian before the end of treatment, unless the parents refuse, there are clear clinical
indications to the contrary, or the minor is emancipated. The clinician may disclose information
to the parent or guardian under certain circumstances as described in ORS 109.680, including
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when the minor’s condition has deteriorated, the minor is at serious risk of suicide, or inpatient
treatment becomes necessary.
C. Mandatory Reporting
Oregon law requires mental health professionals to report suspected child abuse or neglect
(ORS 419B.010), suspected abuse of elderly persons or persons with disabilities (ORS
124.060), and situations where a client poses a clear and immediate danger to others. These
disclosures are made without your authorization as required by law.
D. Oregon Breach Notification
In the event of a breach of your unsecured PHI, federal HIPAA law requires us to notify affected
individuals within 60 days of discovery. Oregon’s general data breach notification law (ORS
646A.604) requires notification within 45 days; however, HIPAA-covered entities that comply
with HIPAA/HITECH breach notification requirements are exempt from Oregon’s general breach
notification law for PHI. As a practice policy, we commit to notifying affected individuals within
45 days of discovery, which exceeds the federal requirement. If the breach affects more than
500 individuals, we must also notify the Secretary of Health and Human Services and prominent
media outlets. If the breach affects more than 250 Oregon consumers, we will also notify the
Oregon Attorney General.
VII. Your Rights Regarding Your Health Information
A. Right to Request Restrictions
You have the right to request restrictions on certain uses and disclosures of your PHI for
treatment, payment, or health care operations. We are not required to agree to your request
unless the restriction involves a disclosure to a health plan for payment or health care
operations purposes and the PHI pertains solely to a health care item or service for which you
have paid out of pocket in full.
B. Right to Receive Confidential Communications
You have the right to request that we communicate with you about health matters in a certain
way or at a certain location. For example, you may ask that we contact you only at a specific
phone number or send mail to a different address. We will accommodate all reasonable
requests.
C. Right to Access Your Records
Oregon law provides a stricter timeline than federal law. Under Oregon law, you have the
right to receive copies of your mental health records within 5 business days of a written request
(compared to HIPAA’s 30-day standard). We will provide you with an electronic or paper copy of
your record, or a summary if you agree. We may charge a reasonable, cost-based fee for
copies.
D. Right to an Accounting of Disclosures
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You have the right to request a list of instances in which we have disclosed your PHI for
purposes other than treatment, payment, health care operations, and certain other activities. We
will respond to your request within 60 days. The accounting will cover disclosures made in the
last six years, unless you request a shorter period. The first accounting in any 12-month period
will be provided at no charge; we may charge a reasonable fee for additional requests within the
same year.
E. Right to Request Amendments
If you believe there is a mistake in your PHI or that important information is missing, you have
the right to request that we correct or add to your records. We may deny your request in certain
circumstances, but we will explain our reasons in writing within 60 days.
F. Right to a Paper or Electronic Copy of This Notice
You have the right to a paper copy of this Notice at any time, even if you have previously agreed
to receive it electronically. You may also request an electronic copy via email.
G. Right to Choose a Personal Representative
If you have given someone medical power of attorney, or if someone is your legal guardian, that
person may exercise your rights and make choices about your health information on your
behalf.
H. Right to Revoke an Authorization
If you provide us with a written authorization to use or disclose your PHI, you may revoke that
authorization in writing at any time. Revocation will not affect any actions we took in reliance on
the authorization before we received your revocation.
VIII. Our Responsibilities
We are required to maintain the privacy and security of your PHI. We will notify you promptly if a
breach occurs that may have compromised the privacy or security of your information. As
described in Section VI.D, our practice policy is to provide notification within 45 days of
discovery, which exceeds the 60-day federal HIPAA requirement.
We will not use or disclose your PHI other than as described in this Notice unless you give us
written authorization. We will not condition treatment on your signing an authorization for uses
or disclosures of PHI that are not related to your treatment.
IX. Records Retention
We retain your mental health records for a minimum of 7 years from the date of the last service
provided, as required by the Oregon Board of Licensed Professional Counselors and
Therapists. HIPAA-related documentation is retained for a minimum of 6 years. For minor
patients, records are retained until the later of the standard retention period or 3 years after the
minor reaches age 18.
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X. How to File a Complaint
If you believe your privacy rights have been violated, you may file a complaint with this practice
or with the federal government. You will not be retaliated against for filing a complaint.
To file a complaint with this practice:
Contact Edgar Julian Caballero, MA, LPC, Privacy Officer Bend Mental Wellness, LLC 64682
Cook Ave #1, Bend, OR 97703 Phone: (541) 357-7686 Email: ok@bendmentalwellness.com
To file a complaint with the U.S. Department of Health and Human Services:
HHS Office for Civil Rights 200 Independence Avenue, S.W., Washington, D.C. 20201 Phone:
(877) 696-6775 Website: www.hhs.gov/ocr/privacy/hipaa/complaints
To file a complaint with the State of Oregon:
Oregon Board of Licensed Professional Counselors and Therapists (OBLPCT) (for complaints
regarding professional conduct of licensed counselors or associates) 3218 Pringle Rd SE, Suite
120, Salem, OR 97302 Phone: (503) 378-5499 Website: www.oregon.gov/oblpct
Oregon Division of Financial Regulation (for insurance-related complaints) Phone: (888) 877-
4894 Website: dfr.oregon.gov
XI. Changes to This Notice
We reserve the right to change this Notice at any time. Any changes will apply to all PHI we
maintain, including information created or received before the change. The current Notice will be
available upon request, posted in our office, and published on our website.
Bend Mental Wellness, LLC | 64682 Cook Ave #1, Bend, OR 97703
This Notice complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
the HITECH Act, and Oregon Revised Statutes including ORS 179.505, ORS 109.675, and ORS
419B.010.
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