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NOTICE OF PRIVACY PRACTICES

Effective Date: 7/8/2026

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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I. OUR PLEDGE REGARDING HEALTH INFORMATION

We understand that health information about you and your health care is personal. We are committed to protecting your health information. We create a record of the care and services you receive to provide you with quality care and to comply with legal requirements. Our responsibilities include:

  • We are required by law to maintain the privacy and security of your protected health information (PHI)

  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your unsecured information.

  • We must follow the duties and privacy practices described in this notice and give you a copy of it.

  • We will not use or share your information other than as described in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

  • We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION

For Treatment, Payment, and Healthcare Operations (TPO): We may use and disclose your PHI to carry out our own treatment, payment, or healthcare operations. 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 PHI to assist in the diagnosis and treatment of your mental health condition. We can use and share your PHI to bill and get payment and in order to run our organization. For example, we may contract with billing agencies or other companies to attend to business needs. We have written contracts in place requiring these business associates to maintain the security of your information in compliance with HIPAA.

Certain Uses and Disclosures Require Your Authorization:

  • Psychotherapy Notes: We may keep "psychotherapy notes" as defined in 45 CFR § 164.501. These are kept separate from your clinical record because they contain the therapist’s private thoughts and clinical impressions, which are not intended for third-party interpretation. Any use or disclosure of these notes requires your separate written authorization, except for: (1) use by the originator for treatment; (2) use in training/supervision; (3) use in defending the therapist in legal proceedings; or (4) use by the Secretary of HHS to investigate compliance.

  • Substance Use Disorder (SUD) Counseling Notes: If we maintain "SUD counseling notes," any use or disclosure requires your separate written authorization, which cannot be combined with consent for other types of records.

Certain Uses and Disclosures Do Not Require Your Authorization: Subject to law, we may disclose PHI without your authorization for:

  • Public health activities. Example: reporting suspected child, elder, or dependent adult abuse or preventing or reducing a serious threat to anyone’s health or safety.

  • Health oversight activities. Example: HHS may review our office’s compliance with regulations.

  • Judicial/administrative proceedings. Examples: court orders, subpoenas.

  • Law enforcement. Example: reporting crimes occurring on my premises.

  • Coroners/medical examiners, research, and to avert a serious threat to health or safety. Example: Helping with safety recalls or efforts aimed at preventing disease.

  • Appointment reminders.

  • 42 CFR Part 2 Limitation: To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena. Information disclosed pursuant to these rules may be subject to redisclosure by the recipient and may no longer be protected by federal privacy standards.

Certain Uses and Disclosures Require You to Have the Opportunity to Object: 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.

III. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

  1. Right to Inspect and Copy: You have the right to inspect or receive an electronic or paper copy of your Clinical Record. We require such requests in writing and will provide a copy of the record or a summary, if you agree to that, within 30 days. We may charge a reasonable, cost-based fee for doing so. Psychotherapy Notes are excluded from this right.

  2. Right to Request a Correction: If you believe there is an inaccuracy in your record, you may request a correction or add an addendum in writing. We may deny the request but will provide a written explanation of the rationale within 60 days of receiving your request.

  3. Right to Accounting of Disclosures: You may request a list of disclosures made in the six years prior to your request (excluding TPO). We will provide this list within 60 days. This includes the right to request an accounting specifically for 42 CFR Part 2 records. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures such as those for which you provided us with an authorization.

  4. Right to Request Restrictions: You may ask us to limit how we use or share your PHI for TPO. We are not required to agree to your request, and we may say “no,” for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.

  5. Right to Out-of-Pocket Restriction: If you pay for a service in full out-of-pocket, you may request that we not disclose information regarding that service to your health plan. We will say “yes” unless a law requires us to share that information.

  6. Right to Confidential Communications: You may request that we contact you in a specific way (e.g., home, office, or cell phone) or at a different address. We will accommodate all reasonable requests.

  7. Right to a Paper Copy: You may request a paper copy of this notice at any time, even if you agreed to receive it electronically.

  8. Right to Breach Notification: You have the right to be notified if a breach of your unsecured PHI occurs.

  9. Right to Choose Someone to Act for You: If you have a legal representative (e.g., power of attorney or legal guardian), they can exercise your rights.

  10. Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us using the information on Page 1. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html. We will not retaliate against you for filing a complaint.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

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