Notice of privacy practices
Last updated October 2, 2026
Draft for attorney review. Not yet in effect.
Effective date: [EFFECTIVE DATE]
This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Who this notice covers
This notice applies to [COMPANY LEGAL NAME] and the licensed clinical psychologists who provide evaluations through our service. In this notice, “we,” “us,” and “our” refer to all of them together. Our privacy officer is [PRIVACY OFFICER NAME], who can be reached at [CONTACT EMAIL].
Our duties
We are required by law to:
- Keep your protected health information (PHI) private and secure
- Give you this notice of our legal duties and privacy practices
- Follow the terms of the notice currently in effect
- Tell you if a breach of unsecured PHI affects you
PHI is information that identifies you and relates to your health, the care you receive, or payment for that care. For our service, it includes your assessment responses, what you share during your video consultation, your diagnosis, your written report, and your billing records.
How we may use and disclose your PHI
We may use and disclose your PHI without your written authorization for the following purposes.
Treatment. To conduct your evaluation and consultation. With your permission, to share your report with a prescriber, therapist, or other provider involved in your care.
Payment. To collect payment for our services and to give you a superbill you can submit to your insurer. We do not bill insurance directly.
Health care operations. To run our service, including quality review, training, auditing, and administrative work. We may share PHI with vendors who help us operate, such as secure storage and video providers. Those vendors sign agreements requiring them to protect your PHI.
Appointment reminders and follow-up. To contact you by email, text, or phone about your appointments or your results.
People involved in your care. With your agreement, or when you cannot object and we judge it to be in your interest, we may share limited information with a family member or someone else involved in your care.
Required by law. When federal, state, or local law requires it.
Public health and oversight. To public health authorities as permitted by law, and to agencies that oversee health care providers.
Serious threat to health or safety. To prevent or lessen a serious and imminent threat to you or others, consistent with applicable law and professional ethics.
Abuse or neglect. To appropriate authorities when we are required to report suspected abuse or neglect.
Legal proceedings. In response to a court order, or in some cases a subpoena or other lawful request, with protections required by law.
Law enforcement. In limited situations permitted by law, such as to report a crime on our premises or in response to a valid legal request.
Other situations. For workers’ compensation, coroners and medical examiners, and specialized government functions, as permitted by law.
Uses that require your written authorization
We will not do the following without your written permission:
- Share psychotherapy notes, where any exist
- Use your PHI for marketing
- Sell your PHI
- Share your PHI with your employer, school, or anyone else outside your care, unless the law requires it
You may cancel an authorization at any time in writing. The cancellation applies to future uses, not to anything we already shared while the authorization was in effect.
Your rights
Get a copy of your record. You may ask for a copy of your assessment responses, report, and other records. We may charge a reasonable, cost-based fee for copies. In rare cases we may deny access, and you may ask for that decision to be reviewed.
Ask us to correct your record. If you believe something is wrong or incomplete, you may ask us to amend it. We may decline in certain cases, and we will tell you why in writing.
Get a list of disclosures. You may ask for an accounting of the times we shared your PHI for reasons other than treatment, payment, operations, or disclosures you authorized, covering up to the past six years.
Ask for restrictions. You may ask us to limit how we use or share your PHI. We are not required to agree, except that we must agree if you pay in full out of pocket and ask us not to share the information with your health plan. Because we do not bill insurance, this applies to your request not to disclose to any insurer.
Ask for confidential communications. You may ask us to contact you in a particular way or at a particular address or number. We will honor reasonable requests.
Choose someone to act for you. A person with medical power of attorney or legal guardianship may exercise your rights.
Get a paper copy. You may ask for a paper copy of this notice at any time, even if you agreed to receive it electronically.
To exercise any of these rights, email [CONTACT EMAIL] or write to us at [REGISTERED ADDRESS].
Changes to this notice
We may change this notice. The new version will apply to all PHI we hold, including information collected before the change. The current notice will always be posted on our website with its effective date.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with us by emailing [CONTACT EMAIL] or writing to [PRIVACY OFFICER NAME] at [REGISTERED ADDRESS].
You may also file a complaint with the US Department of Health and Human Services, Office for Civil Rights, by visiting hhs.gov/ocr/complaints, calling 1-800-368-1019, or writing to 200 Independence Avenue SW, Washington, DC 20201.
We will not retaliate against you for filing a complaint.
Contact
[COMPANY LEGAL NAME] [REGISTERED ADDRESS] Privacy officer: [PRIVACY OFFICER NAME] Email: [CONTACT EMAIL]