Effective on 03/01/2025


The purpose of this notice is to inform you about how medical information about you may be used and disclosed, as well as how to get access to that information. Please read it thoroughly and will full attention.

Our Legal Duty

According to the law, I/we (change to fit you) must:

●Maintain the privacy of your Protected Health Information (PHI).
●Provide you with information about your legal rights and our privacy practices.


Additionally, we are allowed to:

●Amend our privacy practices and this notice at any time, as long as the changes are permitted by law.
●We will, however, update this notice before changing our privacy practices.

Your Protected Health Information

Your medical information will not be used or disclosed without your written permission, unless required by law. By writing to us, you may revoke your authorization. Using or disclosing your information for treatment, payment, or health-related operations does not require your consent.

Your PHI may be used and disclosed for treatment and billing purposes without your consent. Information may be given to office staff, insurance providers, business associates, etc., when appropriate.

Other Disclosures

●If you need emergency treatment, your consent is not necessary if I attempt to obtain it afterward.
●When compelled by federal, state, or law enforcement officials to use or disclose your PHI, I may do so without your consent
●Your personal information may be disclosed if it coincides with the Mandatory Reporting Laws of my state, which normally refer to threats to someone's safety, health, or welfare.

What Rights Do You Have Over Your PHI?

●You are entitled to see and obtain copies of your protected health information. All requests must be in writing, and responses are provided within (TIME PERIOD). In place of a full report, you may receive a summary. You will be charged ______ per page for copies of your PHI.
●If you request a list of the disclosures I have made, it will be provided within 60 days. Records of disclosure are kept for six years excluding law enforcement records or items for which consent has already been given. PHI you provided is subject to amendment under your consent. Any information that you think needs to be corrected or added can be requested by you. You must submit your request and the reason for it in writing. You may receive a written denial if I conclude that the PHI is:
○Complete and accurate
○Information that cannot be disclosed
○Not included in my records
○Authored by someone else.

Privacy Complaints
You can reach me directly by phone at (YOUR PHONE #), by email at (YOUR EMAIL ADDRESS), or by mail at (YOUR ADDRESS). It is required to provide this information to clients receiving psychotherapy under AB 630, Chapter 229 of the Statutes of 2019. The Notice of Privacy Practices (NPP) requires me/us (YOU CHOOSE) to state that you are entitled to notification in the event of a breach.