HIPPA NOTICE OF PRIVACY PRACTICES

Shoshanna Rome Mental Health Services, PLLC
Provider: Shoshanna Rome, LMHC
Effective Date: [Insert Date]

Introduction

This notice explains how your health information may be used and disclosed and how you can access this information. Please review it carefully.

Your health record contains personal information about you and your health. This information, which identifies you and relates to your past, present, or future physical or mental health or condition and related health care services, is called Protected Health Information (PHI). This Notice describes how we may use and disclose your PHI under federal HIPAA regulations, state law in New York (NY), Connecticut (CT), and Pennsylvania (PA), and professional ethical standards. It also outlines your rights regarding access to and control over your PHI.

We are required by law to maintain the privacy of PHI and to provide you with this Notice of our legal duties and privacy practices. We are required to follow the terms of this Notice. We may update this Notice at any time. Any revised Notice will apply to all PHI we maintain and will be made available via our website, by mail upon request, or at your next appointment.

How We May Use and Disclose Your PHI

1. For Treatment

Your PHI may be used and disclosed by those involved in your care to provide, coordinate, or manage your treatment. This includes consultation with clinical supervisors or other treatment team members. PHI will only be shared with other consultants with your written authorization.

2. For Payment

PHI may be used or disclosed to obtain payment for services provided. Examples include verifying insurance coverage, processing claims, or conducting utilization review. If collection efforts are necessary due to non-payment, only the minimum PHI needed will be disclosed.

3. For Health Care Operations

PHI may be used to support our business activities, including quality assessment, licensing, staff training, and administrative tasks. PHI may be shared with third-party service providers (e.g., billing or transcription) under written agreements requiring them to safeguard your PHI. PHI used for teaching or training purposes will only be disclosed with your authorization.

4. Required by Law

We must disclose your PHI upon your request and to the Secretary of the U.S. Department of Health and Human Services to ensure compliance with HIPAA regulations.

5. Uses and Disclosures Without Authorization

HIPAA and state law permit disclosure of PHI without your authorization in limited circumstances, including:

  • Child Abuse or Neglect: Disclosure to state or local agencies as required by law.

  • Judicial and Administrative Proceedings: Disclosure in response to a subpoena, court order, or similar legal process.

  • Deceased Patients: PHI may be disclosed as required by law or with prior consent to family members, executors, or next-of-kin.

  • Medical Emergencies: Disclosure to medical personnel to prevent serious harm.

  • Family Involvement in Care: PHI may be shared with family or close friends involved in care, with your consent or to prevent serious harm.

  • Health Oversight: Disclosure to agencies authorized to conduct audits, investigations, or inspections.

  • Law Enforcement: Disclosure as required by law or in specific circumstances (e.g., identifying suspects, victims, or missing persons).

  • Specialized Government Functions: Disclosure to U.S. military, national security, intelligence, or Department of State officials as required.

  • Public Health: Disclosure to public health authorities for disease prevention or control.

  • Public Safety: Disclosure to prevent or lessen serious and imminent threats to health or safety.

  • Research: Disclosure only after proper approvals or with your authorization.

  • Fundraising: You may opt out of fundraising communications.

  • Verbal Permission: PHI may be shared with family or friends directly involved in your care with your verbal consent.

6. Uses and Disclosures Requiring Authorization

Uses or disclosures not permitted by law require your written authorization, which you may revoke at any time except for disclosures already made. These include:

  • Psychotherapy notes separated from the rest of your record

  • PHI for marketing purposes

  • Sale of PHI

  • Other uses not described above

Your Rights Regarding PHI

  • Right of Access: Inspect or obtain a copy of PHI maintained in a designated record set. Requests may include electronic or paper copies and may be provided to another person.

  • Right to Amend: Request correction or addition to PHI. Denials may be accompanied by a statement of disagreement.

  • Right to an Accounting of Disclosures: Request a list of certain disclosures made without authorization.

  • Right to Request Restrictions: Request limits on PHI use or disclosure for treatment, payment, or operations. We are required to honor requests related to out-of-pocket payments to health plans.

  • Right to Confidential Communication: Request communication in a specific way or location. We may require information about how payment will be handled.

  • Breach Notification: You will be notified of any breaches of unsecured PHI as required by law.

  • Right to a Copy of This Notice: You may obtain a copy at any time.

Complaints

If you believe your privacy rights have been violated, you may file a complaint in writing with:

Shoshanna Rome Mental Health Services, PLLC / Shoshanna Rome, LMHC
Email: insight@shoshannaromecounseling.com
Phone: 838-900-2876
Address: 83 S Bedford Rd, Suite 105, Mount Kisco, NY 10549

You may also file a complaint with the Secretary of Health and Human Services at 200 Independence Avenue, SW, Washington, DC 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.