Notice of Privacy Practices
Template demonstration content. Illustrative, not legal advice.
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.
Effective date: [date on file].
Our Commitment to Your Privacy
Stillwater Psychiatric is required by law to protect the privacy of your protected health information, to give you this notice of our legal duties and privacy practices, and to follow the terms of the notice currently in effect. Protected health information, or PHI, is information that identifies you and relates to your physical or mental health, the care you receive, or payment for that care. Because we are a psychiatric practice, the information in your record is sensitive, and we treat it accordingly.
How We Use and Disclose Your Health Information
The following describes the ways we may use and disclose your protected health information without your written authorization.
Treatment
We use your health information to provide and coordinate your psychiatric care. For example, your prescriber reviews your medication history and prior treatment responses to choose a next step. We may share information with other clinicians involved in your care, such as your obstetrician during a perinatal consultation, your primary care physician, a therapist, or a pharmacy, so that your care is coordinated and consistent.
Payment
We use and disclose your health information to obtain payment for the services we provide. For example, we may share information with your health plan to verify coverage, obtain prior authorization for a treatment such as TMS or Spravato, or submit a claim for a completed visit.
Healthcare Operations
We use and disclose your health information to run the practice. This includes quality review, training, scheduling, care coordination, credentialing of clinicians, and general administrative functions that support safe and reliable care.
Other Permitted Uses and Disclosures
The law permits or requires us to use or disclose your health information in certain other situations without your authorization. These include:
- Appointment reminders and information about treatment options.
- Public health activities and reporting required by law.
- Reporting suspected abuse, neglect, or domestic violence as required or permitted by law.
- Health oversight activities, such as audits and investigations.
- Judicial and administrative proceedings, in response to a valid court order or other lawful process.
- Law enforcement purposes permitted by law.
- Serious threats to health or safety, where disclosure is necessary to prevent or lessen the threat.
- Workers' compensation, as authorized by law.
- Coroners, medical examiners, and funeral directors, as permitted by law.
- Specialized government functions, such as certain military and national security activities.
Uses and Disclosures That Require Your Written Authorization
Some uses and disclosures of your health information will be made only with your written authorization. These include, in most cases:
- Most uses and disclosures of psychotherapy notes, where they are kept.
- Uses and disclosures for marketing purposes.
- Disclosures that would be a sale of your health information.
- Most other uses and disclosures not described in this notice.
If you give us written authorization, you may revoke it at any time, in writing, except to the extent we have already acted in reliance on it.
Your Rights Regarding Your Health Information
You have the following rights regarding the protected health information we maintain about you.
Right to Access and Receive a Copy
You have the right to inspect and receive a copy of your health information, including an electronic copy where we maintain it electronically. We may charge a reasonable, cost-based fee for copies. In limited circumstances we may deny a request, and where the law allows, you may ask for that denial to be reviewed.
Right to Request an Amendment
If you believe information in your record is incorrect or incomplete, you have the right to request that we amend it. We may deny the request in certain cases, and if we do, we will explain why in writing and tell you how to respond.
Right to an Accounting of Disclosures
You have the right to request a list of certain disclosures we have made of your health information. This accounting does not include disclosures made for treatment, payment, healthcare operations, or certain other categories. The first accounting in a twelve-month period is provided at no charge.
Right to Request Restrictions
You have the right to request that we restrict how we use or disclose your health information for treatment, payment, or healthcare operations. We are not required to agree to every request. We will agree to a request to restrict disclosure to a health plan when the disclosure is for payment or operations and you have paid for the service in full out of pocket, except where disclosure is required by law.
Right to Confidential Communications
You have the right to ask us to communicate with you about your health in a particular way or at a particular location. For example, you may ask us to call only a specific number or to send mail to a specific address. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice, even if you have agreed to receive it electronically. Ask the front desk at either location and we will provide one.
Right to Be Notified of a Breach
You have the right to be notified if a breach occurs that may have compromised the privacy or security of your health information.
Our Legal Duties
We are required by law to maintain the privacy of your protected health information, to provide you with this notice of our legal duties and privacy practices, to follow the terms of the notice currently in effect, and to notify you following a breach of unsecured health information. We reserve the right to change the terms of this notice and to make the revised notice effective for all health information we maintain. If we make a material change, we will post the updated notice in our offices and on this website and make copies available on request.
How to File a Complaint
If you believe your privacy rights have been violated, you may file a complaint with the practice. You may also file a complaint with the U.S. Department of Health and Human Services. You will not be penalized or retaliated against for filing a complaint.
To file a complaint with the practice, contact our Privacy Officer:
Privacy Officer, Stillwater Psychiatric
1850 Stemmons Crossing, Suite 410, Dallas, TX 75207
Phone, (214) 555-0432
Email, [address on file]
To file a complaint with the federal government:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue SW, Washington, DC 20201
Phone, 1-877-696-6775
Online, www.hhs.gov/ocr/privacy/hipaa/complaints
How to Contact Us With Questions
If you have any questions about this notice or would like more information about our privacy practices, please contact the Privacy Officer at the address and phone number above.
This page is template demonstration content prepared by DBJ Technologies for a fictional practice. It is illustrative and is not legal advice. A real practice should have its Notice of Privacy Practices reviewed by qualified counsel before use.