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.
Our Legal Duty
We are required by federal law to maintain the privacy of your Protected Health Information (PHI) and to provide you with this Notice of Privacy Practices. We must follow the privacy practices described in this notice while it is in effect. This notice takes effect on October 13, 2025, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make changes in our privacy practices and the new terms of our notice effective for all PHI that we maintain, including PHI we created or received before we made the changes.
What is Protected Health Information (PHI)?
Protected Health Information includes any information that:
- We create or receive about your past, present, or future physical or mental health condition
- Relates to the provision of healthcare services to you
- Contains information that could be used to identify you, such as your name, address, date of birth, or Social Security number
How We May Use and Disclose PHI
Uses and Disclosures for Treatment, Payment, and Healthcare Operations
We may use or disclose your PHI without your written authorization for the following purposes:
Treatment
We may use your PHI to provide, coordinate, or manage your healthcare and related services. This includes consultation with other healthcare providers regarding your care and referral to other providers. For example, we may share your PHI with a psychiatrist who is prescribing medication as part of your treatment plan.
Payment
We may use and disclose your PHI to obtain payment for services we provide. This includes submitting claims to your insurance company, determining coverage and benefits, and collecting payment for services rendered. For example, we may disclose your diagnosis and treatment dates to your insurance company to obtain authorization for services or reimbursement.
Healthcare Operations
We may use and disclose your PHI for our healthcare operations, which include quality assessment, training, business planning, and general administrative activities. For example, we may use PHI to evaluate the quality of services provided or to train staff members.
Other Permitted and Required Uses and Disclosures
We may also use or disclose your PHI without your authorization in the following situations:
As Required by Law
We will disclose PHI when required to do so by federal, state, or local law, including court orders and administrative proceedings.
Public Health Activities
We may disclose PHI for public health activities such as disease prevention and control, reporting child abuse or neglect, or reporting adverse events related to medical devices or medications.
Health Oversight Activities
We may disclose PHI to health oversight agencies for activities authorized by law, such as audits, investigations, inspections, and licensure proceedings.
Judicial and Administrative Proceedings
We may disclose PHI in response to a court order, subpoena, or other lawful process, subject to applicable legal protections.
Law Enforcement
We may disclose PHI to law enforcement officials for purposes such as identifying or locating a suspect, reporting crimes observed on our premises, or responding to legal requests.
Serious Threats to Health or Safety
We may use or disclose PHI when necessary to prevent a serious threat to your health and safety or the health and safety of others. Disclosures will be made only to persons able to help prevent the threat.
Abuse, Neglect, or Domestic Violence
We may disclose PHI to appropriate authorities if we reasonably believe you are a victim of abuse, neglect, or domestic violence, as required by law.
Military and Veterans
If you are a member of the armed forces, we may disclose PHI as required by military command authorities.
Workers' Compensation
We may disclose PHI as authorized by workers' compensation laws or similar programs that provide benefits for work-related injuries.
Coroners, Medical Examiners, and Funeral Directors
We may disclose PHI to coroners or medical examiners for identification purposes, determining cause of death, or other duties as authorized by law.
Uses and Disclosures Requiring Your Authorization
Other uses and disclosures of PHI not covered by this notice or applicable law will be made only with your written authorization. You may revoke your authorization at any time by submitting a written revocation to our practice, though this will not affect disclosures already made based on your authorization.
Psychotherapy Notes
We will not use or disclose your psychotherapy notes without your written authorization, except for our own treatment purposes, training programs, or as required by law.
Marketing
We will not use or disclose your PHI for marketing purposes without your written authorization.
Sale of PHI
We will not sell your PHI without your written authorization.
Your Rights Regarding Your PHI
You have the following rights regarding your Protected Health Information:
Right to Inspect and Copy
You have the right to inspect and obtain a copy of your PHI contained in your medical record and billing records. To inspect or copy your PHI, submit a written request to our Privacy Officer. We may charge a reasonable fee for copying and mailing your records. In certain limited circumstances, we may deny your request to inspect or copy your PHI.
Right to Amend
If you believe that information in your record is incorrect or incomplete, you may request that we amend it. Submit your request in writing to our Privacy Officer and include a reason supporting your request. We may deny your request if the PHI was not created by us, is not part of the records we maintain, is not available for inspection, or is accurate and complete.
Right to an Accounting of Disclosures
You have the right to request a list of certain disclosures we made of your PHI. This list will not include disclosures for treatment, payment, healthcare operations, disclosures made to you, or disclosures made with your authorization. Submit your request in writing to our Privacy Officer.
Right to Request Restrictions
You have the right to request a restriction on the PHI we use or disclose for treatment, payment, or healthcare operations. You also have the right to request that we restrict disclosures to family members or others involved in your care. We are not required to agree to your request, except in cases where you pay out-of-pocket in full for services and request that we not disclose PHI to your health plan for payment or healthcare operations purposes.
Right to Request Confidential Communications
You have the right to request that we communicate with you about your PHI in a certain way or at a certain location. For example, you may request that we contact you only at work or only by mail. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice at any time, even if you have agreed to receive it electronically. You may obtain a copy from our website or by contacting our Privacy Officer.
Right to Be Notified of a Breach
You have the right to be notified if we discover a breach of your unsecured PHI.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact our Privacy Officer using the information below. You will not be penalized or retaliated against for filing a complaint.
Contact Information
If you have questions about this notice, need additional information, or wish to exercise any of your rights, please contact:
Privacy Officer
Manhattan Psychology Practice
123 Park Avenue, Suite 4500
New York, NY 10017
Email: privacy@manhattanpsych.com
Phone: (212) 555-0123
File a Complaint with HHS
You may also file a complaint with the U.S. Department of Health and Human Services:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775
Website: www.hhs.gov/ocr/privacy/hipaa/complaints/
Acknowledgment of Receipt
You will be asked to sign an acknowledgment that you have received a copy of this Notice of Privacy Practices. This acknowledgment will be maintained in your medical record.