OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION

We understand that your health information is personal and we are committed to protecting it. We create a record of the care and services you receive at this practice. We need this record to provide quality care and to comply with legal requirements. This notice applies to all records of your care generated by this practice.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

Treatment:

We may use your health information to provide, coordinate, or manage your healthcare and related services. This includes sharing information with other healthcare providers involved in your care.

Payment:

We may use and disclose your health information to bill and receive payment for services provided to you, including contacting your insurance company for prior authorization or claims processing.

Healthcare Operations:

We may use and disclose your health information for operational purposes including quality assessment, training, accreditation, compliance activities, and business management.

Other Permitted Uses and Disclosures:

• As required by law, including mandatory reporting obligations
• Public health activities (disease reporting, FDA reporting, workplace safety)
• Victims of abuse, neglect, or domestic violence
• Health oversight activities (audits, inspections, investigations)
• Judicial and administrative proceedings (court orders, subpoenas)
• Law enforcement purposes as permitted or required by law
• Coroners, medical examiners, funeral directors
• Organ and tissue donation organizations
• Research, subject to HIPAA requirements
• To avert a serious threat to health or safety
• Military, veterans, national security, and intelligence activities
• Workers’ compensation as authorized by law
• Inmates and law enforcement custodial situations

Substance Use Disorder (SUD) Records – Part 2 Alignment:

Effective February 16, 2026, records relating to substance use disorder treatment that were previously protected under 42 CFR Part 2 are now aligned with HIPAA protections. These records may be used and disclosed for treatment, payment, and healthcare operations under HIPAA with the same protections as other medical records. SUD records may NOT be used against you in criminal proceedings absent a court order meeting specific criteria. A general HIPAA authorization is sufficient for SUD record disclosures – a separate Part 2 consent is no longer required for most purposes.

USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION

We will obtain your written authorization before using or disclosing your PHI for the following purposes:

• Marketing communications (with limited exceptions for treatment communications)
• Sale of your PHI
• Most uses and disclosures of psychotherapy notes
• Any other use or disclosure not described in this notice

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Right to Inspect and Copy:

You have the right to inspect and obtain a copy of your health information. You may request electronic copies in the format maintained by the practice. We may charge a reasonable, cost-based fee. We must respond within 30 days (15 days if the Privacy Rule NPRM is finalized).

Right to Amend:

You may request an amendment to your health information if you believe it is incorrect or incomplete. We may deny the request under certain circumstances but must provide a written explanation.

Right to an Accounting of Disclosures:

You may request a list of certain disclosures we have made of your health information.

Right to Request Restrictions:

You may request restrictions on how we use or disclose your information for treatment, payment, or healthcare operations. We are not required to agree to all restrictions, but we must comply with requests to restrict disclosures to health plans for services you paid for in full out of pocket.

Right to Request Confidential Communications:

You may request that we communicate with you by alternative means or at alternative locations (e.g., sending correspondence to a specific address).

Right to a Paper Copy:

You have the right to obtain a paper copy of this notice at any time, even if you previously agreed to receive it electronically.

Right to Breach Notification:

You have the right to be notified in the event of a breach of your unsecured PHI.

CHANGES TO THIS NOTICE

We reserve the right to change this notice and make the new provisions effective for all PHI we maintain. Revised notices will be posted in our office and available upon request.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with this practice or with the U.S. Department of Health and Human Services, Office for Civil Rights. You will not be retaliated against for filing a complaint.

CONTACT INFORMATION

Privacy Officer: [NAME]

Address: [PRACTICE ADDRESS]

Phone: [PHONE NUMBER]

Email: [EMAIL]

HHS Office for Civil Rights: www.hhs.gov/ocr/privacy/hipaa/complaints