Notice of Privacy Practices

THIS NOTICE EXPLAINS HOW YOUR HEALTH INFORMATION MAY BE USED AND SHARED, AND HOW YOU CAN ACCESS IT. PLEASE READ CAREFULLY.

1. Our Commitment to Your Privacy

We understand that your health information is personal and sensitive. We are committed to protecting it.

As part of your care, we create and maintain records about your treatment and services. These records help us provide high-quality care and meet legal requirements.

This notice applies to all records created by our mental health practice. It explains:

  • How we may use and share your health information

  • Your rights regarding that information

  • Our responsibilities for protecting it

By law, we must:

  • Keep your protected health information (“PHI”) private

  • Provide you with this notice of our legal duties and privacy practices

  • Follow the terms of this notice currently in effect

We may update this notice at any time. Any changes will apply to all of your records and will be available upon request, in our office, and on our website.

2. How We Use and Share Your Health Information

We may use or disclose your PHI in the following ways:

Treatment, Payment, and Health Care Operations

We may use and share your information without your written permission to:

  • Provide, coordinate, or manage your care

  • Process payments for services

  • Run our practice operations

For example, your therapist may consult with another healthcare provider to improve your diagnosis or treatment.

“Treatment” includes coordination between providers, consultations, and referrals. To provide quality care, providers may need full access to your records, so disclosures for treatment are not limited to the “minimum necessary” standard.

Legal Proceedings

If you are involved in a legal matter, we may disclose your health information:

  • In response to a court or administrative order

  • In response to lawful requests (such as subpoenas), when required conditions are met

3. Uses and Disclosures That Require Your Written Authorization

Psychotherapy Notes

We maintain psychotherapy notes as defined by law. These notes require your written authorization to be used or disclosed, except in limited situations such as:

  • Your treatment

  • Training or supervision of clinicians

  • Legal defense if you bring a claim against us

  • Government investigations of compliance

  • When required by law

  • To prevent serious harm

  • Certain oversight or coroner-related duties

Marketing

We will not use or share your PHI for marketing purposes.

Sale of Information

We will never sell your PHI.

4. Uses and Disclosures That Do Not Require Authorization

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

  • Legal requirements: When required by federal or state law

  • Public health and safety: Reporting abuse, neglect, or serious threats

  • Health oversight: Audits, inspections, or investigations

  • Judicial proceedings: Court or administrative orders

  • Law enforcement: Reporting crimes on our premises

  • Coroners/medical examiners: For official duties

  • Research: Under approved conditions

  • Government functions: Military, national security, or correctional settings

  • Workers’ compensation: To comply with applicable laws

  • Appointment reminders and services: To contact you about appointments or treatment options

5. Disclosures Where You Can Object

Family and Others Involved in Your Care

We may share your information with family members, friends, or others involved in your care or payment for your care—unless you object.

In emergencies, we may share information if necessary and discuss consent afterward.

6. Your Rights Regarding Your Health Information

You have the following rights:

1. Request Limits on Use and Disclosure

You may ask us to limit how we use or share your PHI. We may decline if it would affect your care.

2. Restrict Disclosures to Health Plans

If you pay for services out-of-pocket in full, you can request that we not share that information with your health plan.

3. Choose How We Contact You

You can request that we contact you in a specific way or at a specific address. We will honor reasonable requests.

4. Access Your Records

You may request a copy (paper or electronic) of your records, excluding psychotherapy notes.

  • We will respond within 30 days

  • A reasonable fee may apply

5. Request a List of Disclosures

You can request a list of disclosures made over the past six years (excluding routine uses like treatment or payment).

  • One request per year is free

  • Additional requests may incur a fee

6. Request Corrections

If you believe your information is incorrect or incomplete, you may request a correction.
We may deny the request, but we will explain why in writing within 60 days.

7. Get a Copy of This Notice

You may request a paper or electronic copy of this notice at any time.

Effective Date

This notice is effective as of April 1, 2026.

Acknowledgment of Receipt

By checking the box below, you confirm that:

  • You have received and read this Notice of Privacy Practices

  • You understand your rights regarding your health information

  • You agree to the terms outlined in this document

If signing for a minor, you confirm that you are the parent or legal guardian and authorized to sign on their behalf.

If you want, I can also:

  • simplify it further

  • make it more formal/legal, or

  • format it for a website or intake form.