Notice of Privacy Practices for Psychiatric Services

[Practice Name] Psychiatric Services

Effective Date: [Date]

Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we've shared your information
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Special Protections for Mental Health Information

Mental health records receive special protection under state and federal laws. We will obtain your specific authorization before disclosing your information for purposes other than:

• Treatment and coordination of care
• Payment for services
• Required legal reporting
• Emergency situations

Our Uses and Disclosures

We may use and share your information as we:

• Provide mental health treatment
• Bill for your services
• Comply with the law
• Address workers' compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

Our Responsibilities

We are required to:

• Maintain the privacy and security of your protected health information
• Notify you promptly if a breach occurs
• Follow the duties and privacy practices described in this notice
• Get your written permission before sharing psychotherapy notes

For More Information

Contact our Privacy Officer: [Name] [Phone] [Email] [Address]

Changes to the Terms of this Notice

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 upon request, in our office, and on our website.