HIPAA PRIVACY NOTICE

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

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

[Counseling Practice Name] may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your consent. PHI refers to information in your health record that could identify you.

II. Uses and Disclosures Requiring Authorization

[Counseling Practice Name] may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An authorization is required for most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI.

III. Uses and Disclosures with Neither Consent nor Authorization

[Counseling Practice Name] may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If there is reasonable cause to believe that a child has been abused or neglected, [Counseling Practice Name] must report this to the appropriate authorities.
• Adult and Domestic Abuse: If there is reasonable cause to believe that a vulnerable adult has been abused, neglected, or exploited, [Counseling Practice Name] must report this to the appropriate authorities.
• Health Oversight: If a government agency requests information for health oversight activities, [Counseling Practice Name] may be required to provide it.
• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information may be disclosed with your written authorization or a court order.
• Serious Threat to Health or Safety: If you communicate a threat of physical violence against a reasonably identifiable victim, [Counseling Practice Name] must communicate that information to the potential victim and the police.

IV. Patient's Rights

• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of PHI. However, [Counseling Practice Name] is not required to agree to a restriction you request.
• Right to Receive Confidential Communications: You have the right to request to receive confidential communications from [Counseling Practice Name] by alternative means or at alternative locations.
• Right to Inspect and Copy: You have the right to inspect or obtain a copy of PHI in the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.
• Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record.
• Right to an Accounting: You have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization.

V. Therapist's Duties

• [Counseling Practice Name] is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.
• [Counseling Practice Name] reserves the right to change the privacy policies and practices described in this notice. Unless [Counseling Practice Name] notifies you of such changes, however, [Counseling Practice Name] is required to abide by the terms currently in effect.

VI. Complaints

If you are concerned that your privacy rights have been violated, or you disagree with a decision made about access to your records, you may contact [Contact Person/Information] or the Secretary of the U.S. Department of Health and Human Services.

This notice is effective as of [Date].

Please note that this is a general template and may not meet all legal requirements in your jurisdiction.