NOTICE OF PRIVACY PRACTICES

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.

Overview
This Notice of Privacy Practices (the “Notice”) explains how MTM Psychiatry and its affiliated entities (“MTM Psychiatry,” “we,” or “our”) may use and disclose your protected health information (PHI) for treatment, payment, healthcare operations, and other purposes permitted or required by law. The Privacy Rule protects all “individually identifiable health information” held or transmitted by a covered entity or its business associate, in any form or media. This is known as “protected health information (PHI).” Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have specific rights regarding the use and disclosure of your PHI.

Commitment to Privacy
We value your privacy and are dedicated to maintaining the confidentiality of your medical information. We keep records of the medical care we provide and may also receive such records from other providers. These records help us deliver quality care, seek payment for our services, and comply with professional and legal obligations. MTM Psychiatry is required by law to maintain the privacy of your PHI, to provide you with this Notice of our legal duties and privacy practices, and to notify you if a breach occurs that may have compromised the privacy or security of your PHI. We are required to abide by the terms of this Notice.

Authorizations to Use and Disclose Information
To support your care, you may authorize us to share information with specific parties, such as your primary care provider, psychotherapist, school, employer, or family member, by signing an Authorization for Release of Protected Health Information form. You can specify what information to disclose, and you may revoke an authorization to release information at any time in writing, except to the extent that action has already been taken based on your authorization.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION

 We may use and disclose PHI, without an individual’s written authorization, to carry out treatment, payment, and healthcare operations. The examples below illustrate permissible uses and disclosures but are not exhaustive:

  • Treatment: PHI may be used and disclosed for the purpose of providing, coordinating, or managing your health care treatment and related services. For example, PHI may be disclosed during consultation with other treatment team members or when referring a patient to another health care provider.

  • Payment: PHI may be used and disclosed to bill and collect payment for services provided to you. For example, PHI may be disclosed to your insurance company to determine if they will pay for your treatment or to receive reimbursement for services provided to you.

  • Health Care Operations: PHI may be used and disclosed to support our business operations. For example, PHI may be used for quality assessment activities and audits.

  • Business Associates: We may enter into contracts with business associates to provide billing, legal, auditing, and practice management services. In those situations, PHI will be provided to those contractors as is needed to perform their contracted tasks. Business associates are required to enter into an agreement maintaining the privacy of the PHI released to them.

  • Communications: We may use your information to contact you to schedule or remind you of appointments or to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.

 We may also use and disclose your PHI without your authorization for the following reasons, subject to legal limitations:

  • As Required by Law: PHI may be disclosed in compliance with other state and/or federal laws and regulations.

  • Public Health Activities: PHI may be disclosed to public health authorities for public health activities, such as preventing or controlling disease. We may disclose information about communicable diseases as authorized by law.

  • Abuse, Neglect, or Domestic Violence: PHI may be disclosed to government authorities regarding abuse or neglect as required by law.

  • Health Oversight Activities: PHI may be disclosed to health oversight agencies for authorized activities, including audits and investigations.

  • Judicial and Administrative Proceedings: PHI may be disclosed in response to a valid court or administrative order.

  • Law Enforcement Purposes: PHI may be disclosed for law enforcement purposes under certain conditions, such as responding to court orders or identifying suspects.

  • Coroners, Medical Examiners, and Funeral Directors: PHI may be disclosed to coroners, medical examiners, and funeral directors to carry out their duties.

  • Organ and Tissue Donation: PHI may be disclosed to facilitate organ and tissue donations.

  • Research: PHI may be used for research purposes when approved by an institutional review board.

  • Threat to Health or Safety: PHI may be disclosed to prevent or lessen serious and imminent threats to health or safety.

  • Specialized Government Functions: PHI may be disclosed for specialized government functions, including certain military or national security activities.

  • Workers’ Compensation: PHI may be disclosed for workers’ compensation or similar programs.


Special Protections for Substance Use Disorder (SUD) Records
Under federal regulations (42 CFR Part 2 and HIPAA), records related to substance use disorder treatment receive heightened protections:

  • Consent for Disclosure: We will generally obtain your written consent before disclosing SUD records for treatment, payment, or healthcare operations, except in medical emergencies or by court order.

  • Legal Proceedings: Your SUD records, including testimony regarding those records, cannot be used in civil, criminal, administrative, or legislative proceedings against you without your specific written consent or a court order that meets legal requirements.

  • Notice of Redisclosure: Information disclosed under this Notice may be subject to redisclosure by the recipient and may no longer be protected by federal privacy rules. However, SUD records remain subject to strict redisclosure prohibitions.

  • Interaction with Other Laws: When other laws (like 42 CFR Part 2) are more restrictive than HIPAA, the stricter law applies.

YOUR CHOICES

 For certain health information, you can tell us your choices about what we share. Let us know if you have a clear preference for how we share your information in the situations described below and we will follow your instructions.

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

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

  • Share information in a disaster relief situation.

  • Include your information in a hospital directory.

If you are not able to tell us your preference (for example, if you are unconscious), we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to public health or safety.

We may contact you for fundraising efforts, but you will be first provided with a clear and conspicuous opportunity to elect not to receive these communications, and you have the right to opt out of receiving such communications at any time.

In these cases, we will not use or disclose your information unless you give us written permission:

  • Psychotherapy Notes: We may keep and maintain Psychotherapy Notes, which are kept separately from the rest of your record. In most cases, we will obtain written authorization before using or disclosing your Psychotherapy Notes, unless otherwise allowed by law.

  • Marketing purposes

  • Sale of your information

 Other uses and disclosures of your PHI not described in this Notice will only be made with your written authorization. You may revoke an authorization to release information at any time in writing, except to the extent that action has already been taken based on your authorization.

YOUR RIGHTS 

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

  • Get an electronic or paper copy of your medical health record: You can ask to inspect or receive an electronic or paper copy of your medical record and other health information we maintain about you. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee to fulfill your request. If we deny your request, in whole or in part, we will provide a written explanation and will let you know whether you have the option of having the denial reviewed.

  • Ask us to amend your medical record: You can ask us to amend health information about you that you think is incorrect or incomplete. We may deny your request but will provide you with a written explanation within 60 days along with information on how you may submit a statement disagreeing with the denial.

  • Request confidential communication: You can ask us to contact you in a specific way or by a specific means (for example, home or office phone) or to send mail to a different address. We will accommodate all reasonable requests.

  • Ask us to limit what we use or share: You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may deny a request if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will accommodate such requests unless a law requires us to share that information.

  • Request additional restrictions: You have the right to request additional restrictions on the use or disclosure of your health information. We will consider all reasonable requests but are not always required to agree.

  • Get a list of those with whom we’ve shared information: You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting per year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

  • Get a paper copy of this Notice: You can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically.

  • 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. We will make sure the person has this authority and can act for you before we take any action.

  • File a complaint if you feel your rights are violated: If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer by e-mailing info@mtmpsychiatry.com or calling (720) 254-1398. You may also file a complaint with the Secretary of 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 https://www.hhs.gov/hipaa/filing-a-complaint/index.html. We will not retaliate against you for filing a complaint.


Changes to the Terms of this Notice: MTM Psychiatry reserves the right to change the terms of this Notice, and the changes will apply to all the protected health information MTM Psychiatry maintains. The new Notice will be available upon request and on our website.

Effective Date: This Notice is effective February 5, 2026.

For more information: If you have any questions about this Notice, please contact our Privacy Officer by e-mail at info@mtmpsychiatry.com or by phone at (720) 254-1398. Additionally, for more information you may visit www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html