HIPAA Notice / Notice of Privacy Practices

[Therapist Name] Notice of Privacy PracticesEffective Date: [Date]Privacy Contact: [Name, Email, Phone


Your Information. Your Rights. Our Responsibilities.

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

Your Rights

You have the right to:

  • Get a copy of your medical record

  • Correct your medical record

  • Request confidential communication

  • Ask us to limit the information we share

  • Get a list of those with whom we've shared your information

  • Get a copy of this privacy notice

  • Choose someone to act for you

  • File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way we use and share information as we:

  • Tell family and friends about your condition

  • Provide mental health care

  • Market our services and sell your information

Our Uses and Disclosures

We may use and share your information to:

  • Treat you

  • Run our practice

  • Bill for your services

  • Help with public health and safety issues

  • Comply with the law

  • Respond to lawsuits and legal actions

We will never use your psychotherapy notes, market your information, or sell your information without your written permission.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.

  • We will notify you promptly if a breach occurs that may have compromised your information.

  • We will not use or share your information other than as described in this notice unless you give us written permission.

Changes to This Notice

We can change the terms of this notice. Changes will apply to all information we have about you. The new notice will be available upon request and on our website.

Complaints

If you believe your privacy rights have been violated, you may contact us directly or file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights at hhs.gov/hipaa/filing-a-complaint. We will not retaliate against you for filing a complaint.