Legal and Patient Policies

Our practice is committed to transparency, patient rights, and the highest standards of privacy and ethical care. This section provides easy access to important information that helps you understand your protections, your responsibilities, and how we safeguard your personal health information. Within this page, we outline our HIPAA Privacy Notice, our No Surprises Act Disclosure, and your Patient Rights and Responsibilities, ensuring you feel informed, respected, and confident in the care you receive

HIPAA Privacy Notice

Karolina Nicewicz, PsyD

219 South Street, Suite 212

New Providence, NJ 07974

973-348-5118

DrKarolina@MindWellNeuropsy.com

www.MindWellNeuropsy.com

Effective Date: 01/01/2026

Legal Entity: Karolina Nicewicz PsyD LLC, DBA: MindWell Neuropsychology

This Notice describes how medical, psychological, and health information about the patient may be used and disclosed, and how you can access this information. Please review it carefully.

1. Our Legal Duty

MindWell Neuropsychology is required by law to:

Maintain the privacy and security of your protected health information (PHI).

Provide you with this Notice of our legal duties and privacy practices.

Follow the terms of this Notice currently in effect

Notify you promptly if a breach occurs that may compromise the privacy or security of your information.

2. How We May Use and Disclose Health Information

We may use or disclose PHI for the following purposes without your written authorization:

A. Treatment

To provide evaluation and treatment services, coordinate care, consult with other professionals, or communicate with parents/guardians. Examples include:

Reviewing school records

Consulting with other providers involved in your child’s care

Coordinating services with teachers or therapists with your written Release of Information.

B. Payment

MindWell Neuropsychology is an out-of-network, fee-for-service practice. We do not bill insurance or communicate with insurance companies on your behalf.

We may use or disclose PHI to:

Process your payment

Provide a superbill only if you request one

Respond to your questions about charges or status.

C. Healthcare Operations

For administrative, quality improvement, and practice management purposes. Examples include:

Recordkeeping

Scheduling

Training

Internal audits

3. Uses and Disclosures Requiring Written Authorization

We will obtain your written authorization before using or disclosing PHI for any purpose not described in this Notice, including:

Communication with schools, teachers, or outside providers (via Release of Information)

Sharing records with attorneys or third parties

Any use or disclosure not otherwise permitted by law.

You may revoke your authorization at any time in writing.

4. Situations Where We May Disclose Information Without Authorization

We may disclose PHI without your permission when required by law, including:

A. Child Abuse or Neglect

If we suspect abuse or neglect, we must report it to the appropriate authorities.

B. Serious Threat to Health or Safety

If there is a serious risk of harm to the client or others, we may disclose information to prevent or lessen the threat.

C. Legal Proceedings

In response to a court order, subpoena, or other lawful process, as required by law.

D. Public Health and Safety

For public health reporting, health oversight activities, or compliance with government regulations

E. Specialized Government Functions
Such as national security or law enforcement requests, when legally required.

5. Your Rights Regarding Health Information

You have the following rights:

A. Right to Access

You may request to inspect or obtain a copy of your or your child’s records, including evaluation reports. Requests must be made in writing.

B. Right to Request Amendments

If you believe information is incorrect or incomplete, you may request an amendment in writing. We may deny the request if the information is accurate or legally protected.

C. Right to Request Restrictions
You may request limits on how your information is used or shared. We are not required to agree, but we will consider all requests.

D. Right to Confidential Communications
You may request that we contact you in a specific way (e.g., at a certain phone number or email).

E. Right to Accounting of Disclosures

You may request a list of disclosures made in the past six years, excluding those for treatment, payment, or healthcare operations.

F. Right to a Paper or Electronic Copy of This Notice
You may request a copy at any time.

G. Rights of Parents/Guardians

Parents and legal guardians generally have the right to access their child’s records unless restricted by law or court order.

6. Electronic Communication

If you choose to communicate with us by email or telehealth, we will take reasonable steps to protect your privacy. However, electronic communication may carry inherent risks, and absolute security cannot be guaranteed.

7. Our Responsibilities
We are required to:

Maintain the privacy and security of your PHI

Provide you with this Notice

Follow the terms of this Notice

Notify you if a breach occurs

Not use or share your information other than described here unless you authorize in writing.

8. Changes to This Notice
We reserve the right to change the terms of this Notice at any time. Any changes will apply to all PHI we maintain. The updated Notice will be available upon request and posted in our office.

9. Questions or Complaints

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

Karolina Nicewicz PsyD LLC, DBA: MindWell Neuropsychology
Phone: 973-348-5118
Email: DrKarolina@MindWellNeuropsy.com
Address: 219 South Street, Suite 212

New Providence, NJ 07974

You may also file a complaint with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.

10. No Signature Required
This Notice is provided for your information. You do not need to sign or return anything.

No Surprises Act Disclosure

The No Surprises Act is a federal law that helps protect patients from unexpected medical bills for certain services. As an out‑of‑network provider, we are committed to ensuring that you understand the potential costs of your care before services are provided. Because our evaluations and treatment plans may include different tests or procedures based on your individual needs, total charges can vary from patient to patient.

You have the right to receive a Good Faith Estimate explaining the expected costs of your care before your appointment. This estimate outlines the services your provider anticipates may be necessary and the associated fees. If additional testing or services are recommended during your visit, we will review those recommendations with you and discuss any related costs in advance whenever possible.

Under the No Surprises Act, you also have the right to dispute a bill if the final charges are at least $400 more than your Good Faith Estimate. Instructions for initiating a dispute process will be included with your estimate and are available upon request.
Our practice is committed to transparency, open communication, and a predictable financial experience. We encourage you to ask questions about pricing, available options, and what to expect during your visit so you can feel informed and confident in every aspect of your care.

Patient Rights and Responsibilities

Patient Rights

At MindWell Neuropsychology, every patient and family has the right to:

Respect and Dignity

Be treated with compassion, courtesy, and without discrimination

Receive care in a safe, supportive environment.

Information and Understanding

Receive clear explanations about services, evaluation procedures, and recommendations.

Ask questions and have them answered in an understandable language.

Request copies of records as permitted by law.

Privacy

Expect confidentiality of all health information as protected by HIPAA Participation in Care

Participation in Care

Be involved in decisions about your or your child’s evaluation and treatment.

Decline services or withdraw consent at anytime

Financial Transparency

Receive a Good Faith Estimate before services

Understand all fees, policies, and payment expectations.

Patient Responsibilities

To ensure high-quality, effective care, patients, and families are responsible for:

Providing Accurate Information

Sharing relevant medical, educational, and developmental history

Updating contact information and communication preferences.

Attending Scheduled Appointments

Arriving on time and notifying the office promptly of cancellations.

Following the practice’s cancellation and no-show policies.

Participating in the Evaluation Process

Completing questionnaires or forms as requested

Providing school or medical records when needed.

Financial Responsibility

Paying fees at the time of service.

Requesting a superbill if seeking potential out-of-network reimbursement.

Cancellations and no-show fees are administrative charges that are not part of the Good Faith Estimate.

If you have any questions about your rights, responsibilities, or financial transparency, our team is always here to help.