Effective Date: August 15, 2025

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 Responsibilities

• Maintain the privacy and security of your protected health information (PHI).
• Let you know promptly if a breach occurs that may have compromised the privacy or security of your PHI.
• Follow the duties and privacy practices described in this notice.
• Provide you with a copy of this notice upon request.

How We May Use and Share Your Health Information

We typically use or share your health information in the following ways:

• For Treatment: To provide, coordinate, or manage your health care.
• For Payment: To bill and collect payment from you, an insurance company, or a third party.
• For Health Care Operations: To run our practice, improve your care, and contact you when necessary.

Other Ways We May Use or Share Information

• Public Health and Safety: Preventing disease, reporting suspected abuse, reporting adverse reactions.
• Research: Using PHI for health research when permitted by law.
• Compliance with Law: Sharing PHI if required by law.
• Organ and Tissue Donation: Assisting with organ donation and transplant.
• Medical Examiner/Coroner: Working with a medical examiner or funeral director.
• Workers’ Compensation, Law Enforcement, and Government Requests: As required for legal matters.
• Responding to Lawsuits: Sharing information in response to court orders or subpoenas.

Uses and Disclosures That Require Your Authorization

We must obtain your written permission before using or sharing your information for:

• Marketing purposes
• Sale of your PHI
• Most sharing of psychotherapy notes

You may revoke authorization at any time in writing.

Your Rights Regarding Your Health Information

• Get a copy of your medical record: Provided within 30 days; reasonable fees may apply.
• Request corrections: You may ask us to amend incorrect or incomplete information.
• Confidential communications: You may ask us to contact you in a specific way.
• Limit use or sharing: You may request restrictions; if you pay out-of-pocket in full, we must honor.
• List of disclosures: You may request an accounting of disclosures up to six years back.
• Copy of this notice: Available on request in paper or electronic form.
• File a complaint: You will not be retaliated against.

Complaints

If you believe your rights have been violated, you may file a complaint with:

Erica Gonzalez, Privacy Officer
Beth Psychiatry
20855 S Lagrange Rd., Suite 205
Frankfort, IL 60423
Phone: 1-773-985-3539
Email: contact@bethpsychiatry.com

You may also file a complaint with the U.S. Department of Health and Human Services:

Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775
Website: www.hhs.gov/ocr/privacy/hipaa/complaints/

Changes to This Notice

We may change the terms of this Notice. The changes will apply to all information we have about you. Updated notices will be available upon request, in our office, and on our website.