Your rights
Notice of Privacy Practices
Effective October 24, 2026. A sample notice for a fictional practice.
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.
Template note
For template buyers: this sample follows the structure of the model notices published by the U.S. Department of Health and Human Services. HHS updates the requirements from time to time, for example for substance use disorder records. Compare it with the current model notice at hhs.gov, name your real privacy officer and have it reviewed before launch. This is not legal advice.
Your rights
You have the right to get an electronic or paper copy of your records. Ask us, and we’ll usually provide it within 30 days. We may charge a reasonable, cost-based fee.
You can ask us to correct information you think is wrong or incomplete. We may say no, but we’ll tell you why in writing within 60 days.
You can ask us to contact you in a specific way, such as a different phone number or address, and we’ll agree to all reasonable requests.
You can ask us not to use or share certain information for treatment, payment or our operations. If you pay for a service in full yourself, you can ask us not to share that information with your health insurer, and we’ll say yes unless the law requires us to share it.
You can ask for a list of the times we’ve shared your information in the last six years, who we shared it with and why.
You can ask for a paper copy of this notice at any time, and you can choose someone, such as a legal guardian, to act for you.
Your choices
You can tell us whether to share information with family, close friends or others involved in your care. If you can’t tell us, for example if you’re unconscious, we may share it if we believe it’s in your best interest, or when needed to lessen a serious and imminent threat to health or safety.
We never share your information for marketing or sell it without your written permission.
Psychotherapy notes
Some therapists keep personal notes about the content of sessions, separate from your main record. These psychotherapy notes have extra protection: in most cases we can’t use or share them without your written authorization.
How we use and share your information
To treat you: for example, your therapist may consult with a supervisor or another clinician on our team about your care.
To run our practice: for example, to schedule appointments, train associate therapists and improve the quality of our care.
To bill for services: for example, we share information with your health plan to get paid when you use insurance.
Other ways we may share it
The law sometimes requires or allows us to share information, for example to report suspected abuse or neglect of a child or vulnerable adult, to prevent a serious threat to someone’s health or safety, for health oversight, in response to a court order or subpoena, for workers’ compensation claims, and when other laws require it. We share only what’s needed.
Our responsibilities
We’re required by law to keep your health information private and secure, to follow the terms of this notice and to give you a copy of it.
We’ll let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We won’t use or share your information other than as described here unless you tell us we can in writing. You can change your mind at any time by letting us know in writing.
Changes to this notice
We can change the terms of this notice, and the changes will apply to all information we hold about you. The new notice will be available on request, in our offices and on this website.
Questions and complaints
Contact our privacy officer: Maya Okafor, LMFT (sample), 210 Harbor Street, Suite 300, Alder Bay, CA 94000, (555) 010-0142, hello@bowercounseling.example.
If you believe your rights have been violated, you can complain to us or to the U.S. Department of Health and Human Services Office for Civil Rights at hhs.gov/ocr/complaints, by calling 1-877-696-6775, or by writing to 200 Independence Avenue SW, Washington, D.C. 20201. We won’t retaliate against you for filing a complaint.