THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW THE FOLLOWING INFORMATION CAREFULLY.

EFFECTIVE DATE: This notice became effective on February 12, 2025.

I. MY COMMITMENT TO YOUR PRIVACY:

Your privacy is of utmost importance to me. I recognize that your protected health information (PHI) is personal, and I am dedicated to safeguarding it. I maintain records of the care and services provided to you, which are essential for quality care and legal compliance. This notice covers all records generated by this mental health care practice. It outlines how I may use and share your PHI, your rights concerning this information, and my legal responsibilities. I am legally required to:

• Ensure your PHI is kept confidential.

• Provide you with this notice detailing my legal duties and privacy practices.

• Adhere to the terms outlined in the current version of this notice.

Please note, I may revise the terms of this notice. Any updates will apply to all PHI I hold and will be available upon request, in my office, and on my website.

II. PERMISSIBLE USES AND DISCLOSURES OF YOUR PHI:

The following outlines various ways your health information may be used and shared. Each category includes explanations and examples, though not every possible use or disclosure is listed. All permissible uses and disclosures will fit within these categories.

For Treatment, Payment, or Health Care Operations: Federal privacy regulations allow health care providers to use or disclose your PHI without written authorization for treatment, payment, and health care operations. For example, if a clinician consults with another licensed provider about your condition, they may share your PHI to aid in diagnosis and treatment.

Legal Proceedings: If you are involved in legal action, I may disclose PHI in response to court orders, subpoenas, or other lawful processes, provided efforts have been made to inform you or protect the requested information. I may also use or disclose your PHI to defend myself in legal proceedings initiated by you.

III. USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION:

Under certain legal conditions, I may use and disclose your PHI without your authorization for the following purposes:

• Compliance with state or federal laws.

• Public health activities, such as reporting abuse or preventing health threats.

• Health oversight activities like audits and investigations.

• Judicial and administrative proceedings.

• Law enforcement purposes, including reporting crimes on my premises.

• Coroners or medical examiners performing authorized duties.

• Approved research purposes.

• Specialized government functions, such as military missions or national security.

• Workers’ compensation compliance.

• Appointment reminders and information about health-related benefits or services.

IV. USES AND DISCLOSURES REQUIRING YOUR OPPORTUNITY TO OBJECT:

Disclosures to Family and Friends: I may share PHI with family, friends, or others involved in your care or payment unless you object. In emergencies, consent may be obtained after the fact.

V. OTHER USES AND DISCLOSURES:

For uses and disclosures not covered above, I will obtain your written authorization. You can revoke this authorization in writing at any time, except where PHI has already been used or disclosed.

VI. YOUR RIGHTS REGARDING YOUR PHI:

• Request Limits: You can request restrictions on how your PHI is used or disclosed, though I am not obligated to agree.

• Out-of-Pocket Payments: You can restrict disclosures to health plans if you’ve paid in full out-of-pocket.

• Communication Preferences: You may request specific methods or locations for communication.

• Access to Your PHI: You have the right to access and obtain copies of your PHI within 30 days of your request. A reasonable fee may apply.

• Disclosure List: You can request a list of disclosures made outside of treatment, payment, or health care operations.

• Corrections: You may request corrections to your PHI. If denied, I will provide a written explanation.

• Copies of This Notice: You can request a paper or electronic copy of this notice at any time.

VII. COMPLAINTS ABOUT PRIVACY PRACTICES:

If you believe your privacy rights have been violated, you may file a complaint with me or with the Secretary of the Department of Health and Human Services within 180 days of the incident. No retaliatory actions will be taken against you for filing a complaint.

ACKNOWLEDGEMENT OF RECEIPT:

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have specific rights regarding the use and disclosure of your protected health information.