NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Responsibilities

This Notice of Privacy Practices (“Notice”) is provided to you as a requirement of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). We are required by law to follow the terms of this Notice and to maintain the privacy and security of your protected health information (“PHI”).

The law requires us to make sure that medical and mental health information that identifies you is kept private. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. The law also requires us to give you a copy of this Notice of our legal duties and privacy practices to tell you what we do with the medical and mental health information about you.

We reserve the right to change the terms of this Notice at any time and to make the new Notice provisions effective for all protected health information that we maintain. The new Notice will be available, upon request in our office and on our website. 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 give us permission, you may revoke it at any time. This Notice applies to all entities, providers, and staff affiliated with Jefferson Neurobehavioral Group and Family Behavioral Health Center.

The effective date of this Notice of Privacy Practices is October 13, 2025.

What is Protected Health Information (PHI)?

Each time you visit our practice, information is collected about you regarding your physical and mental health. The information we collect about you is called Protected Health Information (PHI). This information goes into your healthcare file at our office and may include all or some of the following:

• • Your history (Developmental, school, work, marital and personal)
  • Reasons you came for treatment (Problems, complaints, symptoms, needs, goals)
  • Diagnosis (Medical terms for your problems or symptoms)
  • Treatment plan (Treatments and other services which we think will be of help to you)
  • Progress notes (What we write down about how you are doing, what we observe, and what you tell us)
  • Records (What we obtain from others who treated you or evaluated you)
  • Psychological test scores and evaluations
  • Information about any medications you took or are taking
  • Legal matters
  • Billing and insurance information

When you understand what is in your medical record and what it is used for, you can make informed decisions about whom, when and why others should have this information.

Although your health record is the physical property of our practice, the information belongs to you. You can inspect, read, or review it. If you want a copy of your health record, we can make one for you. However, we will charge you for the costs of copying and mailing. In some very unusual situations, you cannot see everything that is in your medical record. If you find anything in your medical record that you think is incorrect or missing, you have the right to ask us to amend your record, although in some situations we do not have to agree to do that.

Our Uses and Disclosures

We typically use or share your health information in the following ways. We have not listed every use or release of information within the categories, but all permitted uses will fall within one of the following categories:

To Provide Treatment / Evaluation / Intervention:

• We use your PHI to provide you with psychological treatment, evaluation, and related services.  Services may include:
  • Individual / family or group psychotherapy; forensic / vocational / psychological / educational / neuropsychological testing; treatment planning / intervention; cognitive training; and measuring effects of service.
• We may share or disclose your PHI to others who provide treatment to you.
  • For example, we may share your information with your physician. If a team, such as a psychologist, a tutor and / or a cognitive re-trainer, is treating you at our office we can share your PHI with them so that the services you receive are well coordinated.
• We may refer you to other professionals, educators, or consultants for services that we cannot offer, such as for special testing or treatment. When we do this, we need to tell them some things about you so that they can be aware of our reasons for referral.
• We will often receive copies of the findings and opinions of other professionals and that information will also be entered into your record at our office. If you receive treatment in the future from other professionals, we may also share your PHI with them.

Obtain Payment:

• We may use or share your PHI to bill, collect, and process payments from you as well as from any insurance company, government program (Medicare, Medicaid, Worker’s Comp., etc.), or other person who is responsible for payment.
• We may be contacted by your insurance company to determine what your insurance covers and we may have to tell them about your diagnoses, what treatment / intervention / evaluation you received from our office, and what additional services we expect to render to you.
• We may need to also tell your insurance company about the dates that services were provided, what tests were given, your progress, or other matters to determine what services your insurance plan may reimburse.

For Our Health Care Operations:

• We can use and share your health information to run our practice, improve your care, and contact you when necessary (for example, quality improvement; accreditation; training and supervision; business planning; and customer service). We will not use your information for marketing or fundraising without giving you a choice.
• We may be required to supply some information to some government health agencies so they can study disorders and treatment plans for services that are needed. (Note: If we do use PHI for this purpose, your name and identity will be removed from what we send.)

How Else can we use or share your health information?

Comply with the Law
We are allowed or required to share your information in other ways, usually in ways that contribute to the public good, comply with the law, or protect safety. We must meet many conditions in the law before we can share your information for these purposes.

Help with Public Health and Safety Issues:
The law requires us to use and disclose some of your PHI without your consent or authorization in these situations:

• Reporting suspected child or adult abuse, neglect, or domestic violence.
• Preventing or reducing a serious and imminent threat to anyone’s health or safety.
• Reporting certain diseases, injuries, or vital events; product recalls; or adverse events.

Address Workers’ Compensation, Law enforcement, and other Government Requests
We can use or share health information about you:

• For workers’ compensation claims to assist in determination or eligibility and enrollment in those programs.
• For law enforcement purposes or with a law enforcement official.
• With health oversight agencies for activities authorized by law, such as investigations and audits of the health care system or benefits program.
• By the Secretary of the United States Department of Health & Human Services. The Secretary, or designee, has the right to see your information to insure we are obeying the law.
• For special government functions such as military, national security, and presidential protective services.
• To correctional institutions if you are an inmate or in custody.

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.

Respond to Lawsuits and Legal Actions
We can share health information about you in response to a court or administrative order, and in certain circumstances in response to a subpoena, discovery request, or other lawful process. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order.

Cooperate with Business Associates
We may share information with contractors and vendors who perform services for us. They are called our Business Associates under the law. These business associates need to receive some of your PHI to do their jobs. To protect your privacy, they have agreed to safeguard your PHI.
Examples of our Business Associates include:

• Test publishers we may use to run a computerized scoring and interpretive report for a personality test.
• A copy service we use to reproduce large amounts of records.
• A transcription program we may use to assist with copying your records or therapeutic notes electronically.

Participating in Research
We may use your health information to create “de-identified” information when approved by an institutional review board/privacy board in accordance with applicable law and regulations. After removing information that tells anyone who you are, your de-identified limited medical information may be used for research purposes.

Incidental Disclosures
Your information may be used or disclosed incidentally to a permitted use or disclosure. An example of an incidental disclosure is calling your name in a waiting area for an appointment where others in the waiting area may hear your name called. We will make reasonable efforts to limit these incidental uses and disclosures of your protected health information.

Disaster Relief
We may share your medical information with a public or private disaster relief organization assisting with a disaster or an emergency to notify your family about your condition, status, and location.

Psychotherapy Notes
Psychotherapy notes (as defined by HIPAA) receive special protection, and in most cases, we will not use or disclose them without your written authorization.

OBJECTIONS TO USES AND DISCLOSURES

In certain situations, you have the right to object before your medical information can be used or released. This may not apply if you are being treated for certain mental or behavioral problems. If you do not object after you are given the chance to do so, your PHI may be shared in the following ways:

Family and Friends
We can share some information about you with your family or significant others. We will only share such information with those involved in your care or with others you choose, such as close friends, attorneys, educators, or clergy. We also only share the information that you want us to share, and we will honor your wishes as long as they are not against the law.
Emergencies
If there is an emergency and you are unable 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. If we do share your PHI, in an emergency, we will inform you about this as soon as we can. If you do not approve, we will stop sharing such PHI when allowed by the law. We can also use your PHI to find a family member, a personal representative, or another person responsible for your care and to notify them where you are, about your condition, or of your death.

Other Uses and Disclosures Requiring Your Written Authorization

Other uses and disclosures of your PHI not covered by this Notice, or required by law, will be made only with your written permission. In the following cases we will never share your information unless you give us written permission: (1) marketing purposes, (2) sale of your information, and (3) most sharing of psychotherapy notes. If you authorize us to use or disclose your PHI, you may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or release of such medical information for the purposes covered by your written authorization. We cannot take back, however, any information we previously disclosed with your permission or used in our office for treatment, payment, or operations.

Your Rights Regarding Your Protected Health Information

You also have the following rights regarding your medical information:

Right to Review or Obtain a Copy of Your Medical Records
You have the right to review and obtain electronic or paper copies of your medical information that may be used to make decisions about your care. All requests must be made in writing. We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee for copying, mailing, or other supplies associated with your request. If you request a copy in electronic format, we must provide the information in an electronic format. If there are any fees for the costs of creating this format, we may charge you for them.

In some situations, certain parts of your record may not be available for you to review. These include psychotherapy notes, information gathered for legal proceedings, certain evaluation results restricted by federal law, and information still being used by research studies. In addition, if your psychologist or another healthcare professional believes that releasing specific information could cause harm to you or another person, access may be denied. If this occurs, you will be notified in writing and may request that another licensed healthcare professional review the decision.

Right to Request Restrictions
You have the right to ask that we limit how your information is used or shared for treatment, payment, or healthcare operations. You may also ask us not to share information with certain people involved in your care or payment. Although we are not required to agree to all requests, if we do accept a restriction, we will honor it except in emergencies when information is needed to treat you. If you pay for a service or item out‑of‑pocket in full, you can ask us not to share that information with your health plan for payment or health care operations, and we will say “yes” unless a law requires us to share that information.

Right to Request Confidential Communications
You have the right to request that we contact you in a specific way or at a specific place to protect your privacy. For example, you may ask that we call you only at work, use a particular mailing address, or communicate through email. We will make every reasonable effort to accommodate such requests. You may be asked to provide an alternative way to contact you and to explain how billing or payment should be handled.

Right to Request Amendments or Addendums
If you believe that any information in your record is incorrect or incomplete, you have the right to ask us to correct or add to it. All requests for an amendment must be made in writing and must explain what you believe is inaccurate or missing. If we agree, we will update your record and make reasonable efforts to share the corrected information with others who need it or who may have relied on the incorrect version.

If we deny your request, we will provide a written explanation, and you will have the right to add a statement of disagreement to your record. In addition, we may deny your request if you ask us to amend information:

• Not created by us
• Not part of the medical information kept by us
• Not part of the information which you would be permitted to inspect and copy
• That is accurate and complete

Right to an Accounting of Disclosures
When we disclose your PHI, we keep a record of whom we sent it to, when we sent it, and what we sent. You have the right to ask for a list (called an “accounting”) of certain times we have shared your health information with others during the six years before your request. This list will not include disclosures made for treatment, payment, or healthcare operations; disclosures made to you or with your authorization; or those allowed or required by law for reasons such as national security, law enforcement, or correctional purposes.
If an accounting must be temporarily delayed for legal or investigative reasons, we will notify you when it becomes available.

Right to Receive a Paper Copy of this Notice
You can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically. You may ask us to give you a copy of this Notice at any time. You may review this notice at our websites, www.jeffersonneuro.com  or www.familybehavioralhealthcenter.com.
 
Right to Choose Someone to Act for You
If you have given someone 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.

Right to File a Complaint
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the United States Department of Health and Human Services. To file a complaint with us, please contact your psychologist or provider. You will not be penalized or otherwise retaliated against for filing a complaint.

To file a complaint with The United States Department of Health and Human Services, please call the phone numbers listed below or write to the following address:

The U.S. Department of Health and Human Services
200 Independence Avenue S.S.
Washington, D.C. 20201
Telephone: 202-619-0257
Toll Free: 1-877-696-6775