Heart Mind Body LLC (HMB)

Notice of Privacy Practices & HIPAA Acknowledgment

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

1. Our Commitment to Your Privacy

Heart Mind Body LLC (“HMB”) is committed to protecting the privacy and confidentiality of your health information. We are required by law under the Health Insurance Portability and Accountability Act (HIPAA) to maintain the privacy of your Protected Health Information (PHI) and to provide you with this Notice of our legal duties and privacy practices.

2. What Is Protected Health Information (PHI)?

Protected Health Information includes any information about your physical or mental health, treatment, or payment for services that can identify you.

3. How We May Use and Disclose Your Information

We may use or share your PHI in the following ways:

A. Treatment

We may share information with other healthcare providers involved in your care (e.g., primary care physicians, specialists, therapists) to coordinate treatment.

B. Payment

We may use your information to bill and collect payment from you, insurance companies, or third parties.

C. Healthcare Operations

We may use your information to improve our services, conduct quality reviews, training, and administrative activities.

4. Uses Requiring Your Written Authorization

We will not use or disclose your PHI for the following without your written consent:

• Psychotherapy notes (when applicable)
• Marketing purposes
• Release of records to third parties not involved in your care
• Most disclosures outside treatment, payment, or operations

You may revoke authorization at any time in writing.

5. Situations Where Disclosure Is Required or Permitted by Law

We may disclose your PHI without your consent in the following situations:

• Risk of harm: If there is a serious threat to your safety or the safety of others
• Abuse or neglect: Reporting suspected child, elder, or dependent adult abuse
• Legal proceedings: Court orders or subpoenas
• Law enforcement: As required by law
• Public health: Reporting communicable diseases or health risks
• Workers’ compensation claims

6. Your Rights Regarding Your Information

You have the right to:

• Access and obtain copies of your medical records
• Request corrections to your records
• Request restrictions on certain uses or disclosures
• Request confidential communication (e.g., alternate phone/email)
• Receive an accounting of disclosures
• Receive a paper copy of this Notice

Requests must be submitted in writing.

7. Electronic Communication & Telehealth

HMB may communicate with you via:

• Phone
• Email
• Text messaging
• Telehealth platforms

While we use HIPAA-compliant systems, no electronic communication is completely secure. By signing below, you acknowledge and accept these risks.

8. New Jersey-Specific Considerations

In accordance with New Jersey law:

• Certain mental health, substance use, and HIV-related information may have additional confidentiality protections
• We will comply with all applicable NJ statutes and regulations governing mental health records
• Minor consent and confidentiality laws will be followed where applicable

9. Our Responsibilities

HMB is required to:

• Maintain the privacy of your PHI
• Provide this Notice
• Abide by the terms of this Notice
• Notify you in the event of a breach of your unsecured PHI

10. Changes to This Notice

We reserve the right to update this Notice at any time. Updated versions will be available upon request and on our website.

11. Questions or Complaints

If you have questions or believe your privacy rights have been violated, you may contact:

Privacy Officer
Heart Mind Body LLC
[Insert Address]
[Insert Phone Number]
[Email Address]

You may also file a complaint with the U.S. Department of Health and Human Services (HHS) without fear of retaliation.

CLIENT ACKNOWLEDGMENT OF RECEIPT

I acknowledge that I have received and/or been given the opportunity to review the Notice of Privacy Practices for Heart Mind Body LLC.

I understand my rights regarding my protected health information and how it may be used and disclosed.

Client Name: ______________________________

Signature: ________________________________

Date: _____________________

Parent/Guardian (if applicable): ______________________________