HIPPA Notice of Privacy Practices
Rhythm Wellness Mental Health Counseling PLLC
Effective Date: [Insert Date]
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our Commitment to Your Privacy
Rhythm Wellness Mental Health Counseling PLLC is committed to protecting the privacy of your health information. We are required by law to:
Maintain the privacy of your Protected Health Information (PHI)
Provide you with this Notice of our legal duties and privacy practices
Follow the terms of the Notice currently in effect
Notify you if we are unable to agree to a requested restriction
Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
This Notice applies to all records of your care maintained by Rhythm Wellness Mental Health Counseling PLLC, whether created by our therapists or staff.
What is Protected Health Information (PHI)?
Protected Health Information (PHI) includes:
Information about your past, present, or future physical or mental health condition
Information about healthcare services provided to you
Payment information related to healthcare services
Any information that could identify you (name, address, date of birth, Social Security number, etc.)
How We May Use and Disclose Your Health Information
Uses and Disclosures That Do Not Require Your Authorization
1. For Treatment
We may use and disclose your PHI to provide, coordinate, or manage your mental health treatment and related services. This may include:
Consultation with other healthcare providers about your care
Coordination of care between therapists in our practice (Jack Szary and Lindsay Levine)
Referrals to other mental health professionals or specialists
Emergency treatment situations
Example: If you are working with Jack and need specialized services that Lindsay provides, Jack may consult with Lindsay about your care.
2. For Payment
We may use and disclose your PHI to bill and receive payment for services provided to you. This may include:
Submitting claims to your health insurance company
Verifying insurance coverage and benefits
Collecting payment for services
Responding to insurance company requests for information to justify treatment
Example: We will submit claims to your insurance company that include your diagnosis, dates of service, and types of services provided.
3. For Healthcare Operations
We may use and disclose your PHI for healthcare operations, which include:
Quality assessment and improvement activities
Case management and care coordination
Professional training and education
Business planning and administrative functions
Compliance with legal and regulatory requirements
Example: We may review treatment records to evaluate the quality and effectiveness of our services.
4. Required by Law
We may use and disclose your PHI when required by federal, state, or local law, including:
Reporting suspected abuse, neglect, or domestic violence
Complying with workers' compensation laws
Responding to court orders or legal proceedings
Reporting certain communicable diseases to public health authorities
5. Public Health Activities
We may disclose PHI to public health authorities for activities such as:
Preventing or controlling disease, injury, or disability
Reporting births and deaths
Reporting adverse events related to medications or medical devices
Conducting public health surveillance or investigations
6. Health Oversight Activities
We may disclose PHI to health oversight agencies for activities authorized by law, including:
Audits and investigations
Licensure or disciplinary actions
Civil, administrative, or criminal proceedings
7. Judicial and Administrative Proceedings
We may disclose PHI in response to:
Court orders
Subpoenas (when accompanied by appropriate court orders or patient authorization)
Administrative tribunal orders
8. Law Enforcement
We may disclose limited PHI to law enforcement officials in specific circumstances:
In response to a court order, subpoena, or warrant
To identify or locate a suspect, fugitive, material witness, or missing person
About a victim of a crime (in limited circumstances)
About a death suspected to be the result of criminal conduct
About criminal conduct at our practice
9. To Avert a Serious Threat to Health or Safety
We may use and disclose PHI when necessary to prevent a serious and imminent threat to:
Your health or safety
The health or safety of another person
The public's health or safety
This is often referred to as the "duty to warn" or "duty to protect."
Example: If you communicate a serious threat to harm yourself or another person, we may disclose information to law enforcement, the potential victim, or emergency services.
10. Specialized Government Functions
We may disclose PHI for:
Military and veterans' activities (if you are a member of the armed forces)
National security and intelligence activities
Protective services for the President and others
Correctional institutions (if you are an inmate)
11. Workers' Compensation
We may disclose PHI for workers' compensation or similar programs that provide benefits for work-related injuries or illnesses.
12. Coroners, Medical Examiners, and Funeral Directors
We may disclose PHI to coroners, medical examiners, or funeral directors to:
Identify a deceased person
Determine cause of death
Permit funeral directors to carry out their duties
13. Research
Under certain circumstances, we may use and disclose PHI for research purposes when:
An Institutional Review Board has approved the research
The research involves only de-identified information
You have provided authorization
Uses and Disclosures That Require Your Written Authorization
For uses and disclosures beyond treatment, payment, and healthcare operations, we will obtain your written authorization, including:
Psychotherapy Notes
Psychotherapy notes are the therapist's personal notes about session content, separate from your official medical record. These notes have additional protections and require your specific written authorization for disclosure, except in very limited circumstances.
Note: Most of your treatment records are NOT psychotherapy notes and can be used for treatment, payment, and healthcare operations without separate authorization.
Marketing
We will not use or disclose your PHI for marketing purposes without your written authorization.
Sale of Information
We will not sell your PHI without your written authorization.
Other Uses
Any other use or disclosure of your PHI not described in this Notice will be made only with your written authorization. You may revoke your authorization at any time by providing written notice, except to the extent that we have already taken action in reliance on your authorization.
Special Protections for Certain Information
Mental Health Records
Mental health records in New York State have additional privacy protections beyond HIPAA. We follow both HIPAA and New York State Mental Hygiene Law, whichever provides greater protection.
Substance Abuse Treatment
If you receive treatment for substance abuse issues, those records are protected by federal law (42 CFR Part 2) and generally cannot be disclosed without your specific written consent, except in limited emergency situations.
HIV/AIDS Information
HIV/AIDS-related information has special protections under New York State law and requires specific written authorization for disclosure.
Minors
For clients under 18, parents or legal guardians generally have the right to access health information. However, in certain circumstances (such as when a minor consents to their own treatment under New York law), the minor may have privacy rights that limit parental access.
Your Rights Regarding Your Health Information
You have the following rights regarding your PHI:
1. Right to Inspect and Copy
You have the right to inspect and obtain a copy of your health information, including:
Progress notes
Treatment plans
Assessment reports
Billing records
How to Exercise This Right:
Submit a written request to info@rhythmwellnessnyc.com or mail to our office
We will respond within 30 days (or 60 days if the information is not maintained on-site)
We may charge a reasonable fee for copying and mailing records
Limitations:
We may deny access in certain limited circumstances, such as when a therapist determines that access would cause substantial harm
You may request a review of certain denials
Psychotherapy Notes: We may deny access to psychotherapy notes, which are separate from your regular treatment records.
2. Right to Amend
If you believe information in your record is incorrect or incomplete, you may request an amendment.
How to Exercise This Right:
Submit a written request explaining what should be changed and why
We will respond within 60 days
We may deny your request if the information is accurate, complete, or not created by us
If we deny your request, you may submit a statement of disagreement, which will be included in your record
3. Right to an Accounting of Disclosures
You have the right to request a list of certain disclosures we have made of your PHI.
What's Included:
Disclosures for purposes other than treatment, payment, or healthcare operations
Disclosures not authorized by you
Disclosures made within the past six years (or shorter period if you request)
What's NOT Included:
Disclosures made for treatment, payment, or healthcare operations
Disclosures made to you
Disclosures you authorized
Disclosures to friends or family involved in your care (with your permission)
How to Exercise This Right:
Submit a written request to info@rhythmwellnessnyc.com
The first accounting in a 12-month period is free; we may charge a reasonable fee for additional requests
4. Right to Request Restrictions
You have the right to request restrictions on how we use or disclose your PHI for treatment, payment, or healthcare operations.
Important Notes:
We are NOT required to agree to your request (except in one specific situation described below)
If we do agree, we will comply with your request unless the information is needed for emergency treatment
Special Rule for Self-Pay: If you pay for services out-of-pocket in full and request that we not share information with your health insurance plan, we MUST agree to your request (unless we are otherwise required by law to share the information).
How to Exercise This Right:
Submit a written request specifying what information you want to restrict and to whom the restriction applies
Contact info@rhythmwellnessnyc.com or call 646-875-8927
5. Right to Request Confidential Communications
You have the right to request that we communicate with you about your PHI in a certain way or at a certain location.
Examples:
Requesting that we call your cell phone instead of home phone
Requesting that we mail information to a P.O. box instead of your home address
Requesting that we communicate only via email or patient portal
How to Exercise This Right:
Submit a written request specifying how or where you wish to be contacted
We will accommodate reasonable requests
You do not need to provide a reason for your request
6. Right to a Paper Copy of This Notice
You have the right to receive a paper copy of this Notice at any time, even if you have agreed to receive it electronically.
How to Exercise This Right:
Request a copy via email at info@rhythmwellnessnyc.com
Call 646-875-8927
Download from our website at rhythmwellnessnyc.com
Request a copy during your appointment
7. Right to Be Notified of a Breach
You have the right to be notified if we discover a breach of your unsecured PHI.
How to Exercise Your Rights
To exercise any of the rights described above, please contact:
Privacy Officer: Jack Szary, LMHC
Email: info@rhythmwellnessnyc.com
Phone: 646-875-8927
Mail: 224 W 35th St Ste 500 #652, New York, NY 10001
Most requests should be made in writing. We will respond to your requests within the timeframes required by law.
Our Responsibilities
We are required by law to:
Maintain the privacy and security of your PHI
Provide you with this Notice of our privacy practices
Follow the terms of the Notice currently in effect
Notify you if we are unable to accommodate a requested restriction or confidential communication
Notify you following a breach of unsecured PHI
We reserve the right to:
Change our privacy practices and the terms of this Notice at any time, as long as the changes are permitted by law
Make the new Notice effective for all PHI we maintain, including information created or received before the changes were made
If we make important changes to our privacy practices:
We will post the revised Notice on our website at rhythmwellnessnyc.com
We will provide the revised Notice to active clients
We will make the revised Notice available upon request
Complaints
If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services.
To File a Complaint With Us:
Email: info@rhythmwellnessnyc.com
Phone: 646-875-8927
Mail: 224 W 35th St Ste 500 #652, New York, NY 10001
Please include:
Your name and contact information
Description of the issue or concern
Any relevant dates or details
To File a Complaint With the Federal Government:
U.S. Department of Health and Human Services
Office for Civil Rights
Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Phone: 1-800-368-1019
Mail:
Region II Office
U.S. Department of Health and Human Services
Jacob K. Javits Federal Building
26 Federal Plaza, Suite 3312
New York, NY 10278
You will NOT be retaliated against for filing a complaint.
Questions or Additional Information
If you have questions about this Notice or our privacy practices, please contact:
Rhythm Wellness Mental Health Counseling PLLC
Privacy Officer: Jack Szary, LMHC
Phone: 646-875-8927
Email: info@rhythmwellnessnyc.com
Address: 224 W 35th St Ste 500 #652, New York, NY 10001
Acknowledgment of Receipt
For Our Records:
I acknowledge that I have received a copy of Rhythm Wellness Mental Health Counseling PLLC's Notice of Privacy Practices and have been provided an opportunity to review it.
Client Name (Print): _________________________________
Client Signature: _________________________________
Date: _________________________________
For Minor Clients:
Parent/Guardian Name (Print): _________________________________
Parent/Guardian Signature: _________________________________
Relationship to Client: _________________________________
Date: _________________________________
For Office Use Only
Staff Signature: _________________________________
Date: _________________________________
Notes: _________________________________
Effective Date: [Insert Date]
Last Revised: [Insert Date]
This Notice of Privacy Practices complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR Parts 160 and 164) and applicable New York State laws.