Notice of Privacy Practices
With Love Therapy LCSW, PLLC
Melanie Nichols, LCSW
Effective Date: [Insert date notice takes effect]
Your Information. Your Rights. Our Responsibilities.
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.
With Love Therapy LCSW, PLLC is committed to maintaining the privacy and security of your protected health information (PHI). This Notice explains your rights, the choices you have regarding your information, how we may use or disclose it, and our responsibilities under the Health Insurance Portability and Accountability Act (HIPAA) and applicable New York State laws.
This Notice applies to protected health information maintained by With Love Therapy LCSW, PLLC in connection with its healthcare services.
1. Your Rights
When it comes to your health information, you have certain rights. This section explains those rights and our responsibilities.
Get an Electronic or Paper Copy of Your Medical Record
You may request to inspect or receive an electronic or paper copy of your medical record and other health information we maintain about you.
We will generally provide a copy or summary within 30 days of your request, subject to permitted extensions and exceptions. A reasonable, cost-based fee may apply.
Certain records, including separately maintained psychotherapy notes, may be excluded from the right of access under applicable law.
Ask Us to Correct Your Medical Record
You may request an amendment to information you believe is inaccurate or incomplete.
We may deny a request when permitted by law, but we will explain the reason in writing, generally within 60 days, subject to permitted extensions.
Request Confidential Communications
You may ask us to communicate with you in a particular way, such as through a preferred telephone number, email address, or mailing address.
We will accommodate reasonable requests.
Ask Us to Limit What We Use or Share
You may request restrictions on certain uses or disclosures of your health information for treatment, payment, or healthcare operations.
We are not always required to agree to these requests.
If you pay for a healthcare service entirely out of pocket, you may request that information about that service not be shared with your health plan for payment or healthcare operations. We will honor qualifying requests unless disclosure is required by law.
Get a List of Those With Whom We've Shared Information
You may request an accounting of certain disclosures of your protected health information made during the six years before your request.
Some disclosures, including certain disclosures for treatment, payment, and healthcare operations, are excluded.
One accounting within a 12-month period is provided without charge. Additional requests may involve a reasonable, cost-based fee.
Get a Copy of This Privacy Notice
You may request a paper copy of this Notice at any time, even if you previously agreed to receive it electronically.
Choose Someone to Act for You
If someone has legal authority to act as your personal representative, that person may exercise certain rights regarding your health information.
We will verify that authority and follow applicable federal and New York State laws before granting access.
File a Complaint if You Believe Your Rights Have Been Violated
You may contact With Love Therapy LCSW, PLLC if you believe your privacy rights have been violated.
You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.
We will not retaliate against you for filing a complaint.
2. Your Choices
For certain health information, you may tell us your preferences regarding how your information is shared.
Sharing Information With Family or Others Involved in Your Care
You may tell us whether you want relevant information shared with family members, close friends, or others involved in your care or payment for your care.
If you cannot communicate your preferences, we may disclose information when legally permitted and when we determine that doing so is in your best interest.
Disaster Relief and Safety
We may share relevant information for disaster relief or when necessary to prevent or lessen a serious and imminent threat to health or safety, as permitted by law.
Uses That Generally Require Written Authorization
We will generally obtain your written authorization before:
Using protected health information for marketing purposes when authorization is required.
Selling protected health information.
Using or disclosing separately maintained psychotherapy notes, except as permitted by law.
We do not sell protected health information.
If we conduct fundraising using protected health information, we will follow applicable notice and opt-out requirements.
Substance Use Disorder Information
When we maintain records protected by 42 CFR Part 2, additional confidentiality requirements and patient choices may apply, including requirements concerning fundraising communications and certain disclosures.
3. Our Uses and Disclosures
How Do We Typically Use or Share Your Health Information?
We may use or disclose protected health information without separate written authorization for treatment, payment, and healthcare operations, as permitted by law.
Treatment
We may use your health information and share relevant information with other healthcare professionals involved in your treatment, subject to applicable confidentiality requirements.
For example, with appropriate legal authority, we may coordinate care with another treating healthcare professional.
Healthcare Operations
We may use or disclose information to operate the practice, manage services, maintain records, evaluate quality, and contact you about your care.
Payment
We may use or disclose information to obtain payment for services, including submitting claims to health insurance plans and coordinating permitted billing activities.
When you receive services through an external platform, such as Headway or Alma, information may be handled by that platform according to its role, applicable agreements, and privacy obligations.
How Else May We Use or Share Your Health Information?
Federal and state laws permit or require certain additional uses and disclosures. Applicable legal conditions must be satisfied before information is shared.
Public Health and Safety
We may disclose information when permitted or required for public health activities, reporting suspected abuse or neglect, or preventing or reducing a serious threat to health or safety.
Research
We may use or disclose information for legally authorized research when applicable privacy protections and requirements are satisfied.
Compliance With the Law
We will disclose information when required by applicable federal or state law, including to the U.S. Department of Health and Human Services when necessary to determine compliance with federal privacy requirements.
Organ and Tissue Donation
We may disclose information to organ procurement organizations when legally applicable.
Medical Examiners and Funeral Directors
We may disclose information to a coroner, medical examiner, or funeral director when authorized by law.
Workers' Compensation, Law Enforcement, and Government Requests
Information may be disclosed for workers' compensation matters, legally authorized law enforcement activities, health oversight activities, or certain specialized government functions when applicable requirements are satisfied.
Lawsuits and Legal Proceedings
Information may be disclosed in response to certain court or administrative orders, subpoenas, or other lawful processes, subject to applicable federal and New York State confidentiality protections.
Receipt of a subpoena does not automatically mean that all requested mental health information may be disclosed.
Special Protections for Substance Use Disorder Records
Certain substance use disorder patient records are protected by 42 CFR Part 2.
To the extent we maintain records subject to Part 2, those records generally cannot be used or disclosed in civil, criminal, administrative, or legislative investigations or proceedings against a patient without the patient's written consent or an applicable court order and subpoena or other required legal process.
Additional restrictions may apply to substance use disorder counseling notes, patient consent, and redisclosure of protected records.
We will follow the applicable Part 2 requirements when handling these records.
4. Additional Confidentiality Protections
New York State Mental Health Confidentiality
New York State law may provide additional protections for mental health treatment information beyond those established by HIPAA.
We will follow applicable federal and New York State requirements when using or disclosing mental health records.
Where written authorization is required, information will not be disclosed without that authorization unless another legal basis permits or requires disclosure.
Confidentiality for Adolescent Clients
With Love Therapy LCSW, PLLC provides therapy to adolescents ages 13 and older and adults.
For clients under age 18, consent to treatment, confidentiality, parental or guardian involvement, and access to records are governed by applicable federal and New York State laws.
Depending on the circumstances, adolescents may have confidentiality rights that limit parental or guardian access to certain information.
These rights and the limits of confidentiality will be discussed during the informed consent process.
Psychotherapy Notes
Separately maintained psychotherapy notes may receive special protections under HIPAA.
Written authorization is generally required for their use or disclosure, except in circumstances specifically permitted by law.
5. Our Responsibilities
With Love Therapy LCSW, PLLC is required by law to maintain the privacy and security of protected health information.
We are responsible for:
Maintaining appropriate privacy and security safeguards.
Following the duties and privacy practices described in this Notice.
Providing a copy of this Notice as required by law.
Notifying affected individuals when a breach of unsecured protected health information requires notification.
Obtaining written authorization for uses or disclosures that require it.
Complying with applicable federal and New York State confidentiality laws.
We will not use or share protected health information in ways not described in this Notice unless permitted or required by law or authorized by you in writing.
You may revoke a written authorization at any time by submitting a written request, except to the extent that action has already been taken in reliance on that authorization.
6. Changes to the Terms of This Notice
We may revise this Notice to reflect changes in applicable laws, regulations, or practice operations.
Changes may apply to protected health information already maintained by the practice, as permitted by law.
An updated Notice will be available upon request and on our website.
7. Questions, Requests, and Complaints
If you have questions about this Notice, wish to exercise your privacy rights, or would like to report a privacy concern, please contact:
With Love Therapy LCSW, PLLC
Privacy Contact: Melanie Nichols, LCSW
Phone: (347) 450-8207
Email: hello@withlovetherapypllc.com
Website: www.withlovetherapypllc.com
You may also file a complaint with:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, SW
Washington, DC 20201
Phone: 1-877-696-6775
Website: https://www.hhs.gov/hipaa/filing-a-complaint/index.html
We will not retaliate against anyone for exercising their privacy rights or filing a complaint.