EFFECTIVE DATE: [Insert Date]

This notice describes how medical and mental health information about you may be used and disclosed, and how you can access this information. Please review it carefully.

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OUR COMMITMENT TO YOUR PRIVACY

We are committed to protecting your personal health information. This Notice of Privacy Practices describes how we may use and share your protected health information (PHI), and outlines your rights regarding that information. This notice applies to all services provided by our clinicians and staff.

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HOW WE MAY USE AND DISCLOSE YOUR INFORMATION

We may use or share your health information:

• For Treatment – To provide, coordinate, or manage your care.

• For Payment – To bill and receive payment from insurance or other payers.

• For Healthcare Operations – To run our practice efficiently and ensure quality care.

We may also use or disclose your information in other ways that are permitted or required by law, such as:

• If required by a court order or legal process

• To comply with public health reporting (e.g., abuse, neglect, or risk of harm)

• To protect you or others from serious threats to health or safety

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YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the right to:

• Access Your Record – You may request to view or receive a copy of your clinical records.

• Request Confidential Communications – You can ask us to contact you in a specific way (e.g., at home, by mail).

• Amend Your Record – You may ask to correct information you believe is incorrect or incomplete.

• Limit What We Use or Share – You can ask us not to share certain information, although we may not be able to honor all requests.

• Receive a List of Disclosures – You may ask for a record of times your information was shared outside of treatment, payment, or operations.

• File a Complaint – If you believe your rights have been violated, you can file a complaint with us or with the U.S. Department of Health & Human Services.

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OUR RESPONSIBILITIES

We are required by law to:

• Maintain the privacy of your health information

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

• Follow the terms of this notice

• Notify you if a breach of unsecured health information occurs

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CONTACT US

If you have any questions about this notice or wish to exercise your rights, please contact:

[Psychologist's Name & Practice Name]
[Practice Address]
[Phone Number]
[Email Address]
[Website URL]