Effective: [DATE]
This Practice is committed to protecting your medical information. We are required by law to maintain the privacy of your Protected Health Information ("PHI"), provide you with this Notice describing our legal duties and privacy practices, and follow the terms of the Notice currently in effect.
We may use and share your PHI to provide, coordinate, or manage your healthcare, including consultations with other providers and referrals.
We may use and share your PHI to bill and collect payment from you, your insurance company, or other payers.
We may use and share your PHI to operate this practice, including:
If our practice has multiple providers, your PHI may be accessible to authorized practice administrators and the practice owner for these operational purposes.
Psychotherapy Notes: Notes recorded by your provider during private, group, joint, or family counseling sessions and kept separate from the rest of your medical record have special protection. We will NOT use or disclose these notes without your specific written authorization, except in very limited circumstances (e.g., to defend against a legal action you initiate).
Other state laws may provide additional protection for mental health information, HIV/AIDS status, substance use disorder treatment, and genetic information.
We will obtain your written authorization before using or disclosing your PHI for:
You may revoke an authorization in writing at any time, except to the extent we have already acted in reliance on it.
You have the right to inspect and obtain a copy of your PHI used to make decisions about your care, with limited exceptions. We may charge a reasonable fee for the cost of copying.
You may request that we amend PHI you believe is incorrect or incomplete. We may deny your request in certain circumstances; if we deny, you may submit a written statement of disagreement that will be included in your record.
You may request a list of disclosures we have made of your PHI, other than disclosures for treatment, payment, healthcare operations, or those made with your authorization. The first accounting in any 12-month period is free; we may charge a reasonable fee for additional requests.
You may request restrictions on how we use or disclose your PHI. We are not required to agree to your request, except: we must agree to a request to restrict disclosure to a health plan if the disclosure is for payment or healthcare operations and pertains to a service you paid for in full out-of-pocket.
You may request that we communicate with you in a specific way (e.g., by mail rather than phone) or to a specific location. We will accommodate reasonable requests.
You may request a paper copy of this Notice at any time, even if you have agreed to receive it electronically.
We are required to notify you in writing if a breach of your unsecured PHI occurs.
To exercise any of these rights, please submit a written request to our Privacy Officer at the address below. We will respond within 30 days.
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint.
To file a complaint with HHS:
https://www.hhs.gov/hipaa/filing-a-complaint/
We reserve the right to change this Notice and to make the new Notice apply to PHI we already have, as well as PHI we receive in the future. We will post a copy of the current Notice in our office and on our website. The effective date is shown at the top.