(Revised July 22, 2019)

PBJ Connections, Inc.

Notice of Privacy Practices

Effective October 15, 2006



This notice describes how medical information about you may be used and disclosed, and how you can get access to your health information.


Protecting your privacy

Protecting your privacy and your medical information is at the core of our business.  We recognize our legal and ethical obligation to keep your information secure and confidential whether on paper, oral, or in an electronic form.


How we might use your medical information

We will use your medical information for providing treatment, such as by looking at your records to use your medical history for current treatment; and/or payment, such as when a payer requests copies of your medical information to pay a claim; and/or for healthcare operations, such as for internal auditing.  We may contact you to help provide you with information concerning your health.  We may also contact you to remind you of an upcoming appointment, taking care not to reveal any of your medical information.  You have a right to ask us not to contact you using this method.  I understand that as a part of my healthcare, PBJ Connections, Inc. originates and maintains health records describing my health history, symptoms, examination on test results, diagnosis, treatment, and any plans for future care or treatment for up to seven years after the date of my last session at PBJ Connections, Inc.  I understand that this information serves as a basis for planning my care and treatment, a means of communication among the many health professionals who contribute to my care, a means by which a third-party payer can verify that services billed were actually provided, and a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.


The following circumstances may also require us to use or disclose your health information without your consent or authorization:


  1. To public health authorities and health oversight agencies that are authorized by law to collect information.
  2. Lawsuits and similar proceedings in response to a court or administrative order.
  3. If required to do so by a law enforcement official.
  4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public.
  5. We will only make disclosures to a person or organization able to help prevent the threat.
  6. If you are a member of US or foreign military forces (including veterans) and if required by the appropriate authorities.
  7. To federal officials for intelligence and national security activities authorized by law.
  8. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.
  9. For Workers Compensation or similar programs.


Your rights regarding your health information


  1. You can request that PBJ Connections, Inc. communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than work.  We will accommodate reasonable requests.
  2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment of your care, such as family members and friends.  We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
  3. You have a right to ask for a complete accounting of disclosures that were not authorized or otherwise permitted as listed above. You may revoke your authorization to disclose your medical information at any time.
  4. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records. In order to receive a copy of your records, PBJ Connections will charge you $10 if the request is for more than four (4) pages. The request should be made in writing to PBJ Connections, Inc., Executive Director.  Before receiving your records, you must make an appointment with your therapist, so she can go over your records with you, in case you have any questions.
  5. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for PBJ Connections, Inc. To request an amendment, your request must be made in writing and submitted to PBJ Connections, Inc., Executive Director.  You must provide us with a reason that supports your request for amendment.
  6. You have a right to receive a copy of the Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time.  PBJ Connections, Inc. reserves the right to change their notice and practices and if the terms do change, you may obtain a revised Notice by contacting PBJ Connections, Inc., or by asking the therapist.
  7. You have a right to file a complaint. If you believe that your privacy rights have been violated, you may file a complaint with (1) PBJ Connections, Inc. or with (2) the Secretary of the Department of Health and Human Services.  Both addresses are provided at the bottom of this form.  All complaints must be submitted in writing.  To file a complaint with PBJ Connections, Inc., contact the Executive Director.  You will not be penalized for filing a complaint.
  8. You have a right to provide an authorization for other uses and disclosures. PBJ Connections, Inc. will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.  If you have any questions about this notice or our health information privacy practices, please contact PBJ Connections, Inc.


PBJ Connections, Inc.                                    US Dept. of Health and Human Services

9734 Jug Street Rd.                                         200 Independence Avenue, S.W.

Pataskala, OH 43062                                      Washington DC, 20201

Phone: (740) 924-7543                                   Phone: (202) 619-0257

Fax: (740)-924-2002                                       Web site:



PBJ Connections, Inc.

Client Rights and Responsibilities


Client Rights

  • To receive considerate and respectful services.
  • To receive services which demonstrate sensitivity to and respect for diverse cultural backgrounds.
  • To receive services without regard to ethnicity, sex, age, handicapping condition, national origin, sexual orientation, or economic status.
  • To receive current and complete information concerning his/her diagnosis, treatment, and prognosis in terms he/she can understand from the members of the professional staff assigned to his/her case.
  • To know by name, specialty, and qualifications the members of staff assigned to his/her case.
  • To have the considerations of privacy and individuality as it relates to social, religious and psychological well-being.
  • To have the respectfulness and privacy as it relates to his/her individual care program. Case discussion, consultation, examination, and treatment are confidential and are conducted discreetly.
  • To obtain information on the relationship of PBJ Connections, Inc. to other health care and related agencies insofar as his/her care is concerned.
  • To be fully informed, prior to or at the time of his/her initial appointment, of services available, and of related charges.
  • To participate in the planning of his/her treatment, to be fully informed of any risks or hazards associated with his/her treatment, to refuse treatment, and to refuse to participate in experimental research.
  • To not be arbitrarily discharged, or transferred to another service provider. Clients may be transferred or discharged only for clinical reasons, for his/her welfare, for other clients’ welfare, for nonpayment of services.  Reasonable advance notice of any discharge must be given to a family/client.
  • To be encouraged and assisted to understand and exercise his/her rights and, to this end, have the right to voice grievances and recommend changes in policies and services to PBJ Connections, Inc. staff and outside representatives of his/her choice, free from restraint, interference, coercion, discrimination, or reprisal.
  • To be free from mental and physical abuse, neglect, and exploitation and be free from chemical and physical restraints, except in emergencies, or as authorized in writing by his/her physician or other appropriately licensed professional for a specified and limited period of time, and when necessary to protect the client from injury to him/herself or to others.
  • No client/family shall be required to provide services for PBJ Connections, Inc.
  • To have the assurance of confidential treatment of his/her clinical records and may approve or refuse their release to any individual outside of PBJ Connections, Inc. except as otherwise provided by law, or a third party payment contract.
  • To expect reasonable continuity of care.





Client Responsibilities


  • To keep appointments or notify PBJ Connections, Inc. of necessary cancellations 24 hours in advance.
  • To pay for services to the extent that he/she is able. Services may be refused if a client/family is capable but unwilling to pay.  PBJ Connections, Inc. has a sliding fee scale based on family income, but reserves the right to approve or deny additional funding on a case by case basis.
  • To inform PBJ Connections, Inc. of relevant changes in location or status-address, telephone number, payment coverage, etc.
  • To follow through on service plan recommendations and procedures to which he/she has agreed or to specifically communicate his/her withdrawal of consent to the therapist.
  • To respect the privacy, safety, and property of others.



To report any problems or changes, please contact your therapist. 

If you believe you have been denied any of the above, you may contact PBJ Connections, Inc. by mail at 9734 Jug Street Rd. Pataskala, OH 43062.