PRIVACY PRACTICES
Notice of Privacy Practices
This notice describes how medical and mental health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Effective date: [EFFECTIVE DATE]. NY Integrative Psychological Services, PLLC ("NYIPS," "we") is required by law to maintain the privacy of your protected health information (PHI), to give you this notice of our legal duties and privacy practices, to follow the terms of the notice currently in effect, and to notify you if a breach affects your unsecured PHI.
How we may use and disclose your information
Treatment, payment, and health care operations
Treatment. Your clinician may use your information to provide care and may consult with other NYIPS clinicians as part of our team model. We share information with outside providers, such as a psychiatrist, only with your consent unless the law allows otherwise.
Payment. We use your information to bill you and to prepare superbills at your request. Because we are out-of-network, we do not send information to your insurer unless you ask us to or submit a superbill yourself.
Health care operations. We may use information for quality review, training, and running the practice.
Uses that require your written authorization
We will not use or disclose psychotherapy notes, use your information for marketing, or sell your information without your written authorization. Other uses not described in this notice also require your authorization, which you may revoke in writing at any time.
Disclosures permitted or required by law without authorization
We may disclose information without your authorization in limited situations, including:
To prevent or lessen a serious and imminent threat to your health or safety or that of others.
When required to report suspected abuse or neglect of a child, or of a vulnerable adult, as New York law requires.
In response to a court order or as otherwise required by law.
For health oversight activities, such as audits or licensing investigations.
To public health authorities, coroners, or for specialized government functions, as permitted by law.
For workers' compensation, as authorized by law.
New York law may provide greater protection than federal law for some information, such as HIV-related information and certain mental health records. When it does, we follow the stricter rule.
Your rights
Access. You may request to inspect or get a copy of your records. We may charge a reasonable, cost-based fee.
Amendment. You may ask us to correct information you believe is inaccurate or incomplete.
Accounting of disclosures. You may request a list of certain disclosures we have made.
Restrictions. You may ask us to limit how we use or share your information. If you pay in full out of pocket, you may restrict disclosures to your health plan.
Confidential communications. You may ask us to contact you in a specific way or at a specific address.
Paper copy. You may request a paper copy of this notice at any time.
Breach notification. You will be notified if a breach compromises your unsecured PHI.
Website and contact forms
Our website forms and email are not intended for clinical information. Please share only what's needed to schedule a consultation. We do not sell personal information collected through this site.
Complaints
If you believe your privacy rights have been violated, you may contact our Privacy Officer at intake@nyintegrative.com, or file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights at www.hhs.gov/ocr/complaints. We will not retaliate against you for filing a complaint.
Changes to this notice
We may change this notice, and the change will apply to all information we hold. The current notice will always be posted on this page and available on request.
Privacy Officer: [NAME], NY Integrative Psychological Services, PLLC, [ADDRESS], intake@nyintegrative.com