Dina Siegel PsyD LLC Notice of Privacy Practices 

Dina Siegel PsyD LLC 

11140 Rockville Pike, Suite 437 

Rockville, MD 20852 

NOTICE OF PRIVACY PRACTICES 

Effective Date: 08/01/2025 

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

I. MY PLEDGE REGARDING HEALTH INFORMATION: 

I understand that health information about you and your health care is personal. I am committed to protecting that information. I create a record of the care and services you receive from me, including services provided via telehealth. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated by this mental health care practice, whether provided in-person or via telehealth. 

What is Protected Health Information (PHI)? 

"Protected Health Information (PHI)" refers to any individually identifiable health information that relates to your past, present, or future physical or mental health or condition, the provision of health care to you, or the payment for such health care. PHI includes information such as your name, address, birth date, Social Security number, diagnosis, treatment plan, and medical records—whether in paper, electronic, or oral form. 

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. 

Telehealth Use and Security: 

Services provided through telehealth platforms are conducted using secure, HIPAA-compliant technology. Reasonable safeguards are in place to protect the privacy and security of your PHI during video sessions, messaging, and electronic transmission. I have Business Associate Agreements (BAAs) in place with all telehealth technology vendors to ensure they also comply with HIPAA. 

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: 

For Treatment, Payment, or Health Care Operations: 

I may use or disclose your PHI for treatment, payment, and health care operations without your written authorization. This includes services provided via telehealth platforms. 

Example: If I consult with another licensed health care provider about your condition, this consultation may take place in person or via secure telecommunication. 

Disclosures for treatment purposes are not limited to the minimum necessary standard. 

“Treatment” includes, among other things, coordination and management of care, consultations, and referrals—including those made during or as a result of telehealth services. 

Lawsuits and Disputes: 

If you are involved in a legal dispute, I may disclose your health information in response to a court or administrative order, subpoena, or other lawful process, consistent with HIPAA and state law requirements. 

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: 

Psychotherapy Notes: 

I do keep psychotherapy notes. Any use or disclosure of such notes requires your explicit Authorization except in specific circumstances listed under HIPAA. 

Marketing Purposes: 

I will not use or disclose your PHI for marketing purposes. 

Sale of PHI: 

I will not sell your PHI in the regular course of my business. 

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION: 

I may use or disclose your PHI without your Authorization when: 

Required by law 

In cases of public health and safety 

For health oversight and auditing 

For judicial and administrative proceedings 

For law enforcement purposes 

To coroners or medical examiners 

For research (with safeguards in place) 

For specialized government functions 

For workers’ compensation compliance 

For appointment reminders and health-related services (via phone, text, email, or telehealth message) 

Telehealth-Specific Communication: 

I may contact you by phone, email, or within a secure telehealth platform regarding appointment reminders or other relevant care information, unless you request an alternative method of communication. 

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

If you identify a person (such as a family member or caregiver) to be involved in your care, I may disclose relevant PHI to them, unless you object. This also applies to telehealth services when others may be present or assisting you during sessions. 

VI. YOUR RIGHTS REGARDING YOUR PHI: 

You have the right to: 

Request limits on how your PHI is used or disclosed 

Restrict disclosures to health plans if you paid out-of-pocket in full 

Choose how I communicate with you (e.g., phone, email, secure messaging) 

Access your records, including receiving copies in electronic format 

Request an accounting of disclosures 

Request corrections to your PHI 

Receive a paper or electronic copy of this Notice at any time 

VII. ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE: 

Under HIPAA, you have certain rights regarding the use and disclosure of your PHI. By signing below, you acknowledge that you have received and reviewed a copy of this HIPAA Notice of Privacy Practices, which includes policies related to in person and telehealth services. 

Privacy Officer Contact Information: 

Dina Siegel, Privacy Officer 

Dina Siegel PsyD LLC 

11140 Rockville Pike, Suite 437 

Rockville, MD 20852