NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Our Legal Duties

We are required by law to maintain the privacy of your health information and to provide you with this notice of our legal duties, privacy practices, and your rights regarding your health information. Your health information includes individually identifiable medical, insurance, demographic, and payment information, such as your diagnosis, medications, insurance status, address, and social security number.

Who Will Follow This Notice

This Notice applies to all staff, clinicians, and employees of Bespoke Psychiatric, as well as any independent providers who deliver care at our locations as part of an organized health care arrangement. All such providers may share your health information as necessary to carry out treatment, payment, or health care operations as described in this Notice.

Your Rights

• Request Restrictions: You have the right to request restrictions on how we use or disclose your health information for treatment, payment, or health care operations. We are not required to agree to your request, except in certain circumstances (such as when you pay out-of-pocket in full for a service and request that information not be shared with your health plan).

• Access to Health Information: You may inspect and receive a paper or electronic copy of your health information, with some exceptions. We may charge a reasonable fee for copies or summaries.

• Amendment: You may request that we amend your health information if you believe it is incorrect or incomplete. We may deny your request, but will provide a written explanation.

• Accounting of Disclosures: You have the right to receive an accounting of certain disclosures of your health information made by us in the past six years, excluding disclosures for treatment, payment, and health care operations.

• Confidential Communications: You may request that we communicate with you in a certain way or at a certain location. We will accommodate reasonable requests.

• Notification of Breach: We are required by law to notify you if there is a breach of your unsecured health information.

All requests to exercise these rights must be made in writing. Please contact our Privacy Officer for assistance.

How We May Use and Disclose Your Health Information Without Your Authorization

• For Treatment: We may use and disclose your health information to provide, coordinate, or manage your care and related services.

• For Payment: We may use and disclose your health information to bill and receive payment for services provided to you.

• For Health Care Operations: We may use and disclose your health information for our operations, such as quality assessment, staff training, and accreditation.

• Business Associates: We may disclose your health information to third parties who perform services for us (such as billing or IT support) and who have agreed to safeguard your information.

• Family, Friends, and Others Involved in Your Care: We may disclose relevant health information to family members or others involved in your care, unless you object.

• As Required by Law: We will disclose your health information when required to do so by federal, state, or local law.

• Public Health and Safety: We may disclose your health information for public health activities, to report abuse or neglect, for health oversight activities, or to avert a serious threat to health or safety.

• Judicial and Administrative Proceedings: We may disclose your health information in response to a court or administrative order, subpoena, or other lawful process.

• Law Enforcement: We may disclose your health information to law enforcement officials in certain circumstances.

• Deceased Individuals: We may disclose health information to a coroner, medical examiner, or funeral director as necessary.

• Research: We may use or disclose your health information for research purposes under certain conditions and safeguards.

• Workers’ Compensation: We may disclose your health information as authorized by laws relating to workers’ compensation or similar programs.

• Health Information Exchange: We may participate in electronic health information exchanges to facilitate care coordination and treatment.

Uses and Disclosures Requiring Your Authorization

Certain uses and disclosures of your health information require your written authorization, including:

• Uses and disclosures not described in this Notice

• Most uses and disclosures of psychotherapy notes

• Uses and disclosures for marketing purposes

• Sale of your health information

If you provide authorization, you may revoke it at any time in writing, except to the extent that we have already acted in reliance on your authorization.

Changes to This Notice

We reserve the right to change our privacy practices and the terms of this Notice at any time. Changes will apply to all health information we maintain. The current Notice will be posted in our office and on our website. You may request a copy at any time.

Questions or Complaints

If you have questions about this Notice or believe your privacy rights have been violated, you may contact our Privacy Officer. You may also file a complaint with the U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint.

Contact Information:
Bespoke Psychiatric
6016 S 87th St, Ste 120
Lincoln, NE 68520
Phone: 531-242-6965
Email: reception@bespokepsychiatric.com

Effective Date of Notice: July 30, 2025

Reference: 45 CFR § 164.520

This Notice is provided in accordance with federal and state law. Please review it carefully and keep a copy for your records.