HIPAA NOTICE OF 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 this information carefully.

It is my legal duty to safeguard your protected health information (PHI).

By law I am required to ensure that your PHI is kept private. The PHI constitutes information created or noted by me that can be used to identify you. It contains data about your past or future health condition, the provision of health care services to you, or the payment for such health care. I am required to provide you with this Notice about my privacy procedures.

How I will use and disclose your PHI

Some of the uses or disclosures of your PHI will require your prior written authorization; others, however, will not. I may use and disclose your PHI without your consent for the following reasons:
1. I can use your PHI within my practice to provide you with mental health treatment, including discussing or sharing your PHI with any healthcare professional or other designated person or entity for whom you sign a release.
2. When required by Federal, State, or local law or judicial process.
3. To avoid serious harm to yourself or another person.
4. To report child or elder abuse.

Under federal law you have certain rights regarding the PHI I collect and maintain about you:
1. Request that I restrict certain uses and disclosure of your PHI.
2. Request that I communicate with you by alternate means, such as making records available to be picked up or mailed to an alternate address.
3. Request that we amend your PHI record if you feel that the record is incorrect.

If you have any questions about this notice or any complaints about my privacy practices, please contact the Secretary of the Department of Health and Human Services for the state of Connecticut.

I have read and understand the information provided and acknowledge receipt of this notice.

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Patient name (print)                                                Date

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Patient or authorized person signature                        Relationship to patient