HIPAA Privacy & Consent Rights HIPAA Consent Form HIPAA Notice of Privacy Practices & Consent for Treatment HIPAA Consent Form Name * Name First Name First Name Last Name Last Name Date of Birth * Today's Date * Notice of Privacy Practices This notice describes how your medical information may be used and disclosed and how you can access this information. Neurostry Behavioral Health is committed to protecting your privacy in accordance with HIPAA and applicable Washington State laws. HOW YOUR INFORMATION MAY BE USED Your Protected Health Information (PHI) may be used for the following purposes: Treatment: We may use your information to provide, coordinate, or manage your care, including communication between providers involved in your treatment. Payment: We may use your information to bill and collect payment for services, including sharing information with insurance companies when applicable. Healthcare Operations: We may use your information for quality improvement, compliance, training, and internal administrative operations. OTHER PERMITTED DISCLOSURES We may disclose your information without your written authorization in the following situations: If required by law To prevent serious harm to you or others Suspected abuse or neglect (mandatory reporting) Public health and safety reporting Court orders or legal proceedings CONFIDENTIALITY IN PSYCHIATRIC CARE Mental health records are treated with heightened confidentiality. Certain disclosures require explicit written authorization, except where required or permitted by law. TELEHEALTH PRIVACY As a telehealth provider, Neurostry uses secure, HIPAA-compliant platforms. While we take all reasonable steps to protect your privacy, there are inherent risks with electronic communication. YOUR RIGHTS You have the right to: Access and request a copy of your medical records Request corrections to your records Request restrictions on certain uses/disclosures Request confidential communications File a complaint if you believe your rights have been violated COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with: Neurostry Behavioral Health * Or the U.S. Department of Health and Human Services (HHS).You will not be penalized for filing a complaint. PATIENT CONSENT FOR USE & DISCLOSURE By signing below, I acknowledge that: * I have received and reviewed the Notice of Privacy Practices I understand how my information may be used and disclosed I consent to the use of my information for treatment, payment, and healthcare operations I understand I may revoke this consent in writing at any time Patient Signature * signature keyboard Clear Today's Date * Submit If you are human, leave this field blank.
