Notice of HIPAA Privacy Practices

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 AND REPORT ANY ISSUES OR CONCERNS TO: [Clinician Name and Email Address] (We).

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal law requiring that all medical records and other individually identifiable health information used, or disclosed, by us in any form, whether electronically, via video or teleconference, or orally, are kept properly confidential. HIPAA gives you, the Patient, the right to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse protected health information.

We have prepared this "Notice of HIPAA Privacy Practices" (Notice) to explain how we are required to maintain the privacy of your health information and how we and our business associates such as Receptive Inc. d.b.a ADHDAdvisor.org may use and disclose your health information. We are required by law to maintain the privacy of your protected health information and will notify you if there is a breach of your unsecured protected health information. We must follow the terms of this Notice and we may amend the Notice if we change any of our privacy policies or practices. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new notice will be available on Receptive Inc. d.b.a ADHD Advisor's.org, website and in the patient portal [Healthie].

We may use and disclose your medical records for each of the following purposes: treatment, payment, and health care operations:

• TREATMENT means providing, coordinating, or managing health care and related services by one or more health care providers.
• PAYMENT means such activities as obtaining payment or reimbursement for services, billing or collection activities and utilization review.
• HEALTH CARE OPERATIONS include managing your patient portal [Healthie] to facilitate therapeutic consultations, as well as conducting quality assessment review and service improvement planning activities, auditing functions, and customer service. We work with Receptive Inc. d.b.a ADHDAdvisor.org, our business associate, to maintain your protected health information.

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes, including:

Help with public health and safety issues: We can share health information about you to prevent disease, help with product recalls, report adverse reactions to medications, report suspected abuse, neglect, or domestic violence, or prevent or reduce a serious threat to anyone's health or safety.

Comply with the law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we comply with federal privacy law.

With Your Authorization: We will share information about you with those designated by you with your express written authorization. These uses include using your psychotherapy notes for treatment, training, or defense in a legal action or proceeding brought by you, marketing, or selling your information.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide information about our services or other health-related services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to [Clinician Name and Email Address].

You have the right to ask for restrictions on the ways we use and disclose your health information for treatment, payment, and healthcare operations. You may also request that we limit our disclosures to persons assisting your care. We will consider your request, but are not required to accept it.

You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail.

Except under certain circumstances, you have the right to inspect and copy medical, billing and other records used to make decisions about you. If you ask for copies of this information, we may charge you a nominal fee for copying, packaging, and postage.

If you believe that information in your records is incorrect or incomplete, you have the right to ask us to correct the existing information or add the missing information. Under certain circumstances, we may deny your request, such as when the information is accurate and complete.

You have a right to receive a list of certain instances when we have used or disclosed your medical information. If you ask for this information from us more than once every twelve months, charges may apply, to cover our costs for administration, archive retrieval, copying, packaging, and postage. Upon request, you have a right to receive a paper copy of this notice.

You can complain if you feel we have violated your rights by contacting us at (760) 284-5368. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

This Notice is effective [July 1, 2024].