Your Information. Your Rights. Our Responsibilities.
In this notice, your health information means your substance use disorder patient record as well as your other mental health records.
This notice (HIPAA & 42 CFR Part 2- for Substance Use Disorders) describes:
• HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
• YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
• HOW TO FILE A COMPLAINT CONCERNING A VIOLATION OF THE PRIVACY OR SECURITY OF YOUR HEALTH INFORMATION, OR OF YOUR RIGHTS CONCERNING YOUR INFORMATION
YOU HAVE A RIGHT TO A COPY OF THIS NOTICE (IN PAPER OR ELECTRONIC FORM) AND TO DISCUSS IT WITH YOUR PROVIDER AT 866-220-8371 IF YOU HAVE ANY QUESTIONS.
Please review it carefully.
Your Rights
You have the right to:
•Get a copy of your paper or electronic medical record
•Correct your paper or electronic medical record
•Request confidential communication
•Ask us to limit the information we share
•Consent to most uses and disclosures of your health information
•Get a list of those with whom we’ve shared your information or records, including third parties
•Get a copy of this privacy notice
•Choose in advance whether to receive fundraising communications
•Discuss this notice with your provider or our privacy office, Dr. Michelle Chaban- drchaban@associates-in-psychotherapy.com
•Choose someone to act for you
•File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices and can provide your consent for the way that we use and share information as we:
•Tell family and friends about your condition
•Provide disaster relief
•Include you in a hospital directory
•Provide mental health care
•Market our services and sell your information
•Raise funds
With your consent, we can also use and share your information as we (42 CFR Part 2):
•Treat you
•Run our organization
•Bill for our services
•Fulfill your requests to share information with your consent
•Prevent multiple program enrollments
•Report about court-referred treatment
•Report to prescription drug monitoring programs
Our Uses and Disclosures
We may use and share your information as we:
•Help with public health and safety issues
•Do research
•Comply with the law
•Respond to organ and tissue donation requests
•Work with a medical examiner or funeral director
•Address workers’ compensation, law enforcement, and other government requests
•Respond to lawsuits and legal actions
To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.
We may use and share your information without your consent as we (Substance Use Disorder Records-42 CFR part 2):
•Communicate within our program and with our contractors
•Help with medical emergencies
•Help with public health
•Report crimes (and threats of crimes) on our premises and suspected child abuse and neglect
•Aid scientific research
•Respond to audits and evaluations of our program
•Assist cause of death inquiries
•Respond to court orders
In all these circumstances, we must protect your information and limit how we use and share it.
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
•You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
•We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
•You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
•We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
•You can ask us to contact you in a specific way (for example, home, office, or cell phone) or to send mail to a different address.
•We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
•You can ask us not to use or share certain health information for treatment, payment, or our operations after you have provided consent for all those purposes. We are not required to agree to your request, and we may say “no,” for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.
•If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
•You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
•We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
•You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
•If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
•We will make sure the person has this authority and can act for you before we take any action.
Provide consent when we use or share your information for most purposes (For Substance Use Disorders 42 CFR Part 2)
•You may provide a single consent for all future uses or disclosures for treatment, payment, and health care operations purposes.
•You may provide consent for more limited purposes (for example, to only disclose information to another health care provider for your treatment); however, doing so may affect the services we can provide you or how you pay for services.
•You may provide a general consent to share your information through certain third parties, such as a health information network or a research institution, where your treating health care providers can access it.
Discuss this notice with someone in our group practice.
•You can ask questions or obtain more information about this notice and our privacy practices by calling or emailing the contact person at the top of this notice.
Choose in advance about fundraising
•You have the right to a clear and obvious notice in advance of, and a choice about whether to receive, fundraising communications for our program.
File a complaint if you feel your rights are violated
•You can complain if you feel we have violated your rights by contacting us.
•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 https://www.hhs.gov/hipaa/filing-a-complaint/index.html.
•We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices and provide your consent about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
•Share information with your family, close friends, or others involved in your care or payment for your care
•Share information in a disaster relief situation
•Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
•Marketing purposes
•Sale of your information
•Most sharing of psychotherapy notes
In the case of fundraising:
•We may contact you for fundraising efforts, but you can tell us not to contact you again.
If we have your substance use disorder patient records, subject to 42 CFR part 2, we will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.
Our Uses and Disclosures
How do we typically use or share your health information?
With your consent, we typically use or share your health information in the following ways.
Treat you
•We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
•We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
•We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
With your consent, we may also use and share your information in the following ways (42 CFR Part 2):
•To whomever you name in a consent to share your information
•To prevent multiple enrollments in withdrawal management or maintenance treatment programs
•To report participation in treatment required by the criminal justice system
•To report prescribed substance use disorder treatment medications to a state prescription drug monitoring program when required by law
You can choose someone to act for you.
•If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
•We will make sure the person has this authority and can act for you before we take any action.
How else can we use or share your health information?
•We are allowed or required to share your information in other ways, without your consent – 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.
•In all cases, including those listed below, if we have substance use disorder patient records about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena.
Help with public health and safety issues
We can share health information about you for certain situations such as:
•Preventing disease
•Helping with product recalls
•Reporting adverse reactions to medications
•Reporting suspected abuse, neglect, or domestic violence
•Preventing or reducing a serious threat to anyone’s health or safety
Do research
•We can use or share your information for health research.
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’re complying with federal privacy law.
Respond to organ and tissue donation requests
•We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
•We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
•For workers’ compensation claims
•For law enforcement purposes or with a law enforcement official
•With health oversight agencies for activities authorized by law
•For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
•We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Disclosures subject to Substance Use Disorders 42 CFR part 2)
To communicate within our program and with contractors
•We can share your information within our program (this applies to Substance Use Disorders 42 CFR part 2), with an organization that has administrative control over our program, and with contractors who help us run our program.
For medical emergencies
•We can share your information during a bona fide medical emergency with the personnel and health care providers responding to your emergency, even when you are unable to consent because of the emergency.
•We can also share your identifying information to assist the federal Food and Drug Administration in notifying you or your doctor about unsafe products you may be using.
Help with public health
We can share health information that does not identify you for certain situations such as:
•Preventing disease
•Reporting adverse reactions to medications
Aid scientific research
•We can use or share your information to conduct or help with health research. Researchers cannot include any patient identifying information in their reports about the research.
Respond to management and financial audits and program evaluations
•We can use or share your information to improve the quality of our services, obtain needed credentials, and cooperate with oversight agencies for activities authorized by law, as long as those who view or receive the information agree to destroy or return the information when they are finished and agree not to use it against you.
Assist with cause of death inquiries
•We can share patient identifying information about a deceased patient as required or allowed by laws that collect information relating to cause of death.
Report suspected child abuse and neglect
•We will only report the information required by law.
Prevent or reduce crime in our program
•We may report to law enforcement when a patient commits or threatens to commit a crime within our program or against our staff.
Our Responsibilities
•We are required by law to maintain the privacy and security of your protected health information.
•We are required to obtain your consent for most uses and sharing of your information.
•We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
•We must follow the duties and privacy practices described in this notice and give you a copy of it.
•We will not use or share your information other than as described in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Redisclosure According to HIPAA
When you consent to uses and disclosures for all future treatment and payment purposes and to run our business, we may share your information with other substance use disorder treatment programs, doctors’ offices, and health care businesses for those activities. If the person who receives it is subject to HIPAA, then they are allowed to use and share your information again without your consent for the purposes that HIPAA allows. Your information still cannot be used in legal proceedings against you unless (1) you consent or (2) based on a Part 2 court order and a subpoena (or similar legal requirement).
Legal Proceedings and Court Orders
We must follow certain procedures before using or sharing your information for investigations and legal proceedings.
•We will not use or share your information or provide testimony about your information in any civil, administrative, criminal, or legislative proceedings against you without your written consent or a court order.
•We will only respond to a court order to use or share your health information if it is accompanied by a subpoena or other similar legal mandate requiring us to comply.
•We will only use or share your information in proceedings against you based on a court order after we have received notice and an opportunity to be heard or you tell us that you have received notice.
•We may use or share your information to respond to legal proceedings against our program based on a court order and you may not be notified in advance. You have the right to seek to overturn or change the court order after you learn about it.
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 web site.
•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 https://www.hhs.gov/hipaa/filing-a-complaint/index.html.
•We will not retaliate against you for filing a complaint.
Effective Date
This notice is effective as of February 1, 2026
Other Instructions for Notice
•Dr. Michelle Chaban, Privacy Officer; drchaban@associates-in-psychotherapy.com tel: 866-220-8371
•We will provide you with a summary of your treatment history upon request.