Privacy & Policy

Confidentiality & Privacy Policy

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:

·      Suspected abuse, exploitation, or neglect of a child, vulnerable adult, or elder, which I am required by law to report to the appropriate authorities immediately.

·      If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.

·      Need to protect another's property (Vermont) 

·      If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.

·      See Notice of Privacy Practices below for additional information about privacy and use of your 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. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. 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.
  • I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

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 about your child 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.


  1. Psychotherapy Notes. I may 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: a. For my use in treating you. b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c. For my use in defending myself in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e. Required by law and the use or disclosure is limited to the requirements of such law. f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. g. Required by a coroner who is performing duties authorized by law. h. Required to help avert a serious threat to the health and safety of others.
  2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
  3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

  1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
  2. 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.
  3. For health oversight activities, including audits and investigations.
  4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
  5. For law enforcement purposes, including reporting crimes occurring on my premises.
  6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
  7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
  8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
  9. 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.
    10 Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.


  1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.


  1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
  2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
  3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
  4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
  5. The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
  6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
  7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.





Your health record contains personal information about you and your health.  This information, which may identify you and relates to your past, present or future physical or mental health or condition and related health care services, is referred to as Protected Health Information (“PHI”).  This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law.  It also describes your rights regarding how you may gain access to and control your PHI.

I am required by state and federal law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI.  I am required to abide by the terms of this Notice of Privacy Practices.  I reserve the right to change the terms of the Notice of Privacy Practices at any time.  The most current privacy notice will be posted on my website and available upon request.

Uses and Disclosures for Treatment, Payment, and Health Care Operations

Dr. Jadkowski may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes.

Uses and Disclosures Requiring Authorization

Dr. Jadkowski may use or disclose PHI in certain situations that require your written permission. In the event you provide authorization, you should know that you can revoke that authorization any time unless Dr. Jadkowksi has acted in reliance upon it. Said revocation must be in writing.

Uses and Disclosures that do not require Consent or Authorization

Dr. Jadkowski may use or disclose PHI without your consent or authorization in the following circumstances:

·       Abuse – If Dr. Jadkowski has reason to believe that a minor child, elderly person or disabled person has been abused, abandoned, exploited or neglected, she is required to report this to the appropriate authorities.

·       Health Oversight Activities – If the Massachusetts Board of Registration of Psychologists is investigating a formal complaint, Dr. Jadkowski may be required to disclose protected health information.

·       If you are involved in a court proceeding and a court subpoenas information about the professional services provided you and/or the records thereof, Dr. Jadkowski may be compelled to provide the information.  Although courts have recognized a therapist-patient privilege , there may be circumstances in which a court would order Dr. Jadkowski to disclose personal health or treatment information.

·       If you communicate to Dr. Jadkowski an explicit threat of imminent serious physical harm or death to identifiable victim(s), she is legally obligated to take the appropriate measures to prevent harm to that person(s) including disclosing information to the police and warning the victim.

·       If Dr. Jadkowski has reason to believe that you present a serious risk of physical harm or death to yourself, she may need to disclose information in order to protect you.

·       Dr. Jadkowski may disclose your protected health information to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

·       Dr. Jadkowski may be required to disclose PHI to military authorities or National Security officials that may be required for lawful intelligence, counterintelligence, and other national security activities.

Patient’s Rights and Psychologist’s Duties

·       Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of your clinic health records. A reasonable fee may be charged for copying or, if necessary, redacting the record.  Access to your records may be limited or denied under certain circumstances, but in most cases, you have a right to request a review of that decision.  On your request, we will discuss with you the details of the request and denial process.

·       Right to Amend - You have the right to request in writing an amendment of your health information for as long as PHI records are maintained.  The request must identify which information is incorrect and include an explanation of why you think it should be amended.  If the request is denied, a written explanation stating why will be provided to you.  You may also make a statement disagreeing with the denial, which will be added to the information of the original request.  If your original request is approved, we will make a reasonable effort to include the amended information in future disclosures.  You do not have a right to have information deleted fromi your clinical records.

·       Right to an Accounting –You generally have the right to receive an accounting of disclosures of PHI.  If your health information is disclosed for any reason other than treatment, payment, or operation, you have the right to an accounting for each disclosure.  The accounting will include the date, name of person or entity, description of the information disclosed, the reason for disclosure, and other applicable information.  If more than one (1) accounting is requested in any twelve (12) month period, a reasonable fee may be charged.

·       Right to Request Confidential Communication.  You have the right to request that I communicate with you about medical matters in a certain way or at a certain location.

·       Breach Notification. If there is a breach of unsecured protected health information concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself.

·       You have a right to request an electronic copy of your clinical record if it is stored electronically. You also have the right to obtain a paper copy of the notice from Dr. Jadkowski upon request.

Dr Jadkowski’s Responsibilities:

·       Dr. Jadkowski is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices.

·       Dr. Jadkowski may be required to inform her clients of any breach of confidentiality to their PHI, unless it can be demonstrated that there is a low probability that PHI has been compromised.

·       Dr. Jadkowski reserves the right to change the privacy policies and practices described in this notice.

Other Restrictions:

·       Couples and families seeking treatment will be asked to sign individual consent forms, and further understand that the record of treatment services provided will be released upon written request from either adult present. Should such a request be made, Dr. Jadkowski will notify the other adult present and offer to provide a duplicate copy to that person.

·       Dr. Jadkowski will retain all records related to your treatment for a period of seven years after completion of treatment or seven years after the 18th birthday of a minor who received treatment,

For additional information see:


If you believe that I have violated your privacy rights, because I am the Contact Person of this practice, you may file a complaint to me as well as the Secretary of Health and Human Services.  You may file a complaint with me by providing me with a writing that specifies the manner in which you believe the violation occurred, the approximate date of such occurrence, and any details that you believe will be helpful for me.

I will not retaliate against you for filing a complaint with me or with the Secretary.  Complaints to the U.S. Dept. of Health and Human Services must be filed in writing and sent to:

Secretary of Health and Human Services, Office for Civil Rights, US Department of Health and Human services, JFK Federal Building, Room 1875, Boston, MA 02203.

For additional information regarding the complaint process please go to:

No Surprise Billing Act 160 (OMB Control #0938-1401)

The following is a summary of form I provide for patients paying outside of insurance. The actual form provided at outset of treatment is more detailed and includes a cost estimate. 

The following describes your protections against unexpected medical bills. It also asks if you’d like to give up those protections and pay more for out-of- network care.

IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider before scheduling care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less.

If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records.


You’re getting this notice because this provider or facility isn’t in your health plan’s network and is considered out-of-network. This means the provider or facility doesn’t have an agreement with your plan to provide services. Getting care from this provider or facility will likely cost you more.

If your plan covers the item or service you’re getting, federal law protects you from higher bills when: 

• You’re getting emergency care from an out-of-network provider or facility, or

• An out-of-network provider is treating you at an in-network hospital or ambulatory surgical center without getting your consent to receive a higher bill.

Ask your health care provider or patient advocate if you’re not sure if these protections apply to you. If you sign this form, be aware that you may pay more because:

• You’re giving up your legal protections from higher bills. • You may owe the full costs billed for the items and services you get.

• Your health plan might not count any of the amount you pay towards your deductible and out- of-pocket limit. Contact your health plan for more information.

Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, you can also ask your health plan if they can work out an agreement with this or a different  provider or facility to lower your costs. 

Rachel Jadkowski, PsyD will provide you with a Good Faith Estimate for what you will pay. It is difficult to determine the length of mental health treatment so this provider will offer you an estimate for a year of  therapy on an annual basis. 

Out-of-network provider(s)or facility name:__Rachel Jadkowski

►Review your estimate. 

►Call your health plan. Your health plan may have better information about how much you’ll be asked to pay. You will pay your provider Rachel Jadkowski, PsyD directly, and she will provide a bill for you and your insurance. You can submit this bill to your health insurance if they offer out of network reimbursement. You also can ask about what’s covered under your plan and your provider options. Some plans offer out of network reimbursement and others do not. Call your health plan to find out whether they offer out of network reimbursement, how they handle out of network reimbursement, how much reimbursement they provide, and whether they require preauthorization for out of network reimbursement.

►Questions about this notice and estimate? Ask your provider, Rachel Jadkowski

►Questions about your rights? The federal phone number for information and complaints is: 1-800-985-3059

Prior authorization or other care management limitations

Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover the items or services before you can get them. If your plan requires prior authorization, ask them what information they need for you to get coverage.

Understanding your options

You can also call your health plan for a list of providers who accept your insurance

More information about your rights and protections

Visit for more information about your rights under federal law.

By signing, I understand that I’m giving up my federal consumer protections and may have to pay more for out-of-network care.

With my signature, I’m agreeing to get the items or services from Rachel Jadkowski, PsyD

With my signature, I acknowledge that I’m consenting of my own free will and I’m not being coerced or pressured. I also acknowledge that:

• I’m giving up some consumer billing protections under federal law.

• I may have to pay the full charges for these items and services, or have to pay additional out- of-network cost-sharing under my health plan.

• I was given a written notice on the date I signed this document that explained my provider or facility isn’t in my health plan’s network, described the estimated cost of each service, and disclosed what I may owe if I agree to be treated by this provider or facility.

• I got the notice electronically, and can request a paper copy as well.

• I fully and completely understand that some or all of the amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.

• I can end this agreement by notifying the provider or facility in writing before getting services.

I understand I can ask my provider Rachel Jadkowski any questions about a more detailed estimate, cost, or my rights under the No Surprise Billing Act.

Notice: Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act  (OMB Control Number 0938-XXXX)

 You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit (or call CMS at 1-800-985-3059) or call the Vermont Secretary of State Office of Professional Regulation at (802) 828-1505 at 89 Main Street, 3rd Floor, Montpelier Vermont 05602


This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to (or call CMS at 1-800-985-3059) or call the Vermont Secretary of State Office of Professional Regulation at (802) 828-1505.

 For questions or more information about your right to a Good Faith Estimate or the dispute process, visit (or call CMS at 1-800-985-3059)  or call the Vermont Secretary of State Office of Professional Regulation at (802) 828-1505.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

IMPORTANT: You don’t have to sign this form. If you don’t sign, this provider or facility might not treat you, but you can choose to get care from a provider or facility that’s in your health plan’s network.

Take a picture and/or keep a copy of this form. It contains important information about your rights and protections.

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