Notice of Privacy Practices 

MY PLEDGE REGARDING HEALTH INFORMATION:
 

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
 

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

 

 

YOUR RIGHTS

 

When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you. You have the right to: 
 

• Get an electronic or paper copy of your medical record. You can ask to see or get an electronic or paper copy of your medical record and other health information I have about you. I will provide a copy or a summary of your health information, usually within 30 days of your request. In most situations, I am allowed to charge a copying fee of $0.10 per page (and for certain other expenses). If I refuse your request for access to your records, you have a right of review, which we will discuss with you upon request.

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• Ask to correct your medical record. You can ask me to correct health information about you that you think is incorrect or incomplete. I may say “no” to your request, but I’ll tell you why in writing within 60 days.

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• Request confidential communications. You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address. I will say “yes” to all reasonable requests.

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• Ask me to limit what I use or share. You can ask me not to use or share certain health information for treatment, payment, or our operations. I am not required to agree to your request, and I may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or our operations with your health insurer. I will say “yes” unless a law requires me to share that information.

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• Get a list of those with whom I’ve shared information. I never market or sell personal information. You can ask for an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process. I never market or sell personal information.

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• Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will promptly provide you with a paper copy.

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• 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. I will make sure the person has this authority and can act for you before taking any action. 

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• File a complaint if you feel your rights are violated. You can complain if you feel I have violated your rights by contacting me. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. I will not retaliate against you for filing a complaint. 

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YOUR CHOICES 

For certain health information, you can tell me your preferences about what I share. If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions. 

 

In these cases, you have both the right and choice to tell us to: 

• Share information with your family, close friends, or others involved in your care or payment for your care

• Share information in a disaster relief situation 

• Include your information in a hospital directory

 

We may also share your information when needed to lessen a serious and imminent threat to health or safety 

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In these cases we never share your information unless you give us written permission: 

• Marketing purposes 

• Sale of your information 

• Most sharing of psychotherapy notes 

 

If I have your substance use disorder patient records, subject to 42 CFR part 2, I will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.

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USES AND DISCLOSURES

 

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

 

Treatment: I can use your health information and share it with other professionals who are treating you. 

 

Practice management: I can use and share your health information to run my practice, improve your care, and contact you when necessary. 

 

Billing: I can use and share your health information to bill and get payment from health plans or other entities. 

 

Help with public health and safety issues: I can share health information about you for certain situations such as:

• Preventing disease

• Preventing or reducing a serious threat to anyone’s health or safety

• Reporting suspected abuse, neglect, or domestic violence

Compliance with the law: I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

 

Respond to lawsuits and legal actions: I can share health information about you in response to a court or administrative order, or in response to a subpoena.

• To the extent that I have your substance use disorder patient records, subject to 42 CFR part 2, I will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

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How else can I use or share your health information?  I am allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. I must meet many conditions in the law before I can share your information for these purposes. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

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MY RESPONSIBILITIES: 

 

• I am required by law to maintain the privacy and security of your protected health information. 

• I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• I must follow the duties and privacy practices described in this notice and give you a copy of it. 

• I will not use or share your information other than as described here unless you tell me in writing, and you may change your mind at any time. Let me know in writing if you change your mind. 

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CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
 

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
 

CHANGES TO THE TERMS OF THIS NOTICE

I can change the terms of this notice, and the changes will apply to all information I have about you. The new notice will be available upon request and on my website. 

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EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on 02/16/2026

 

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​Weston Donaldson, Ph.D., ABPP, Licensed Psychologist

Proud Heart Therapy Services, LLC (Owner, Privacy Officer)