THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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

We may use or disclose your protected health information (“PHI”) for treatment, payment, and health care operations purposes with your consent. For clarity:

• “PHI” means information in your health record that can identify you.
• Treatment involves providing, coordinating, or managing your health care and related services. For example, consulting with your primary care physician or another psychologist.
• Payment includes activities to obtain reimbursement for your health care, such as submitting PHI to your insurer to verify coverage or process claims.
• Health Care Operations refer to activities related to the administration and management of our practice, such as quality assessment, audits, case management, and care coordination.

The term “Use” refers to activities within our practice involving your PHI, such as sharing or analyzing it.
“Disclosure” refers to releasing or sharing your PHI outside our practice.

II. Uses and Disclosures Requiring Authorization

We will obtain your written authorization before using or disclosing PHI for purposes beyond treatment, payment, or health care operations. This includes:

• Use or disclosure of psychotherapy notes, which are separate from the rest of your medical record and receive special protections.
• Any use or disclosure of PHI not described in this Notice.
• Any disclosure constituting a sale of PHI.
• Disclosure of substance abuse treatment records or HIV-related information.

You may revoke authorizations in writing at any time, except where we have relied on the authorization or it was required to obtain insurance coverage and the insurer has legal rights to contest claims.

III. Uses and Disclosures Without Consent or Authorization

We may use or disclose PHI without your consent or authorization under certain circumstances, including but not limited to:

• Child Abuse: Reporting suspected child abuse or neglect as required by law.
• Adult and Domestic Abuse: Reporting suspected abuse or exploitation of vulnerable adults.
• Health Oversight: Disclosing PHI pursuant to investigations or proceedings by licensing or regulatory authorities.
• Judicial or Administrative Proceedings: Releasing PHI when compelled by a valid court order or subpoena, except in cases where privilege applies.
• Serious Threat to Health or Safety: Disclosing PHI to prevent or lessen a serious threat to health or safety of yourself or others.
• Worker’s Compensation: Providing PHI as required for worker’s compensation claims.
• Other disclosures permitted by law for public health, law enforcement, government functions, or as otherwise mandated by federal or state law.

IV. Client Rights and Psychologist Duties

Client Rights

• Right to Request Restrictions: You may request restrictions on certain uses or disclosures of your PHI; however, we are not required to agree.
• Right to Confidential Communications: You may request communications by alternative means or at alternative locations.
• Right to Inspect and Copy: You have the right to review and obtain copies of your PHI used for decision-making about your care, with some exceptions.
• Right to Amend: You may request corrections to your PHI, subject to our review.
• Right to an Accounting of Disclosures: You can request a record of certain disclosures of your PHI.
• Right to a Paper Copy of This Notice: You may request a physical copy of this Notice at any time.
• Right to Restrict Disclosures to Health Plans: If you pay out-of-pocket in full for services, you may request restrictions on disclosures to your health insurer.
• Right to Notification of Breach: You will be notified if there is a breach of your unsecured PHI that compromises its security or privacy.
• Right to Authorize a Representative: You may designate a person to act on your behalf, such as via medical power of attorney or legal guardianship, upon verification.

Psychologist Duties

We are legally required to maintain the privacy of your PHI and provide this Notice of our privacy practices. We reserve the right to amend these practices and will notify you of any material changes by your next appointment, telephone, or mail communication.

V. Complaints

If you believe your privacy rights have been violated or you disagree with decisions regarding access to your records, please file a complaint with the U.S. Department of Health and Human Services:
200 Independence Ave, S.W., Washington, D.C. 20201
Phone: 1-877-696-6775

No retaliation will be taken against you for filing a complaint.

VI. Breach Notification Procedures

1. Upon suspecting or confirming a breach of unsecured PHI, we will conduct a Risk Assessment and maintain written documentation of that assessment.
2. Unless a low probability of compromise is determined, we will notify affected individuals and appropriate authorities in compliance with HIPAA breach notification rules.
3. Business associates involved in the breach will conduct risk assessments as applicable; however, we retain responsibility for notification.
4. Post-breach, we will review and enhance privacy and security practices to mitigate future risks.

VII. Effective Date and Changes

This Notice is effective as of July 1, 2025. We may update this Notice periodically and will provide you with the updated version at your next visit or by mail.

If you have any questions regarding this Notice or your rights, please contact us directly.