NOTICE OF PRIVACY PRACTICES

Effective Date: 7th September 2026

EMPATHRA Mental Health Services
4040 North Central Expressway Dallas, TX 75204
Phone: (214) 380-2987
Email:info@empathramental.com

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.

EMPATHRA Mental Health Services (“EMPATHRA,” “we,” “us,” or “our”) is committed to protecting the privacy of your health information.

This Notice of Privacy Practices (“Notice”) explains how we may use and disclose your protected health information (“PHI”), your rights regarding your PHI, and certain responsibilities we have regarding the privacy and security of your information.

This Notice applies to PHI created or received by EMPATHRA in connection with providing health care services to you.

We are required by law to maintain the privacy of your PHI, provide you with this Notice describing our legal duties and privacy practices, and follow the terms of the Notice currently in effect.

When it comes to your health information, you have certain rights.

You may request to inspect or obtain a copy of the health information that EMPATHRA maintains about you.

We may charge a reasonable, cost-based fee where permitted by law.

There are certain circumstances in which we may deny access to particular information as permitted or required by law.

You may ask us to correct health information about you that you believe is incorrect or incomplete.

Your request must be made in writing and should explain why you believe the information should be corrected.

We may deny your request in certain circumstances permitted by law. If we deny your request, we will provide you with an explanation of the reason for the denial and information about your right to submit a statement of disagreement where applicable.

You may ask us to contact you in a specific way or at a particular location.

For example, you may request that we contact you only by telephone, by email, or at a particular mailing address.

We will consider reasonable requests and will accommodate them when required by law.

You may ask us not to use or disclose certain health information for treatment, payment, or health care operations.

We are not required to agree to every restriction request.

However, if you pay for a health care service or item entirely out of pocket and request that the information concerning that service or item not be disclosed to your health plan for payment or health care operations, we will generally agree to that request unless disclosure is required by law.

You may request a list of certain disclosures we have made of your health information.

This accounting generally covers disclosures made during the six years preceding your request, subject to exceptions permitted by law.

Certain disclosures, including disclosures for treatment, payment, and health care operations, are generally excluded from the accounting.

You may request a paper copy of this Notice at any time.

You may also request an electronic copy where available.

If you have given someone medical power of attorney or if someone is your legal guardian, that person may exercise your rights and make decisions regarding your health information when authorized by applicable law.

We will verify the person’s authority before allowing them to act on your behalf.

If you believe your privacy rights have been violated, you may file a complaint with EMPATHRA or with the U.S. Department of Health and Human Services Office for Civil Rights.

You will not be retaliated against for filing a complaint.

For certain health information, you may have choices about what we share.

You may ask us to limit or restrict certain disclosures involving:

• Family members or friends involved in your care;
• Individuals involved in paying for your care;
• Disaster-relief activities; and
• Other circumstances where HIPAA gives you the right to make a choice.

If you have a specific preference regarding how we communicate with you or how certain information is shared, please contact us using the information provided in this Notice.

The following describes common circumstances in which EMPATHRA may use or disclose your PHI without obtaining additional written authorization, as permitted by HIPAA.

We may use or disclose your health information to provide, coordinate, or manage your health care.

For example, a mental health professional involved in your care may use your health information to evaluate your condition, develop a treatment plan, coordinate services, or communicate with another health care provider involved in your treatment.

We may use or disclose your health information to obtain payment for health care services we provide.

For example, we may provide information to your health insurance plan to obtain payment for services or determine whether your insurance will cover a particular service.

We may use or disclose your health information for health care operations.

Health care operations may include activities such as quality assessment, administrative activities, compliance, auditing, training, business planning, and other activities necessary to operate our practice and provide services effectively.

We may use your health information to contact you regarding appointments, scheduling, treatment-related matters, or other health care services.

We may contact you by telephone, voicemail, text message, email, patient portal, mail, or other communication methods that you have provided or that are permitted by law.

We may disclose relevant health information to a family member, close friend, or another person you identify as being involved in your care or payment for your care when permitted by law.

We may also make disclosures to people involved in your care when you are present and do not object, or when professional judgment indicates that disclosure is appropriate.

We may use or disclose your health information when federal, state, or local law requires us to do so.

We may disclose health information for certain public health activities permitted or required by law.

These activities may include reporting certain diseases, injuries, medical conditions, or other information to public health authorities.

We may disclose health information to appropriate government authorities when required or permitted by law to report suspected abuse, neglect, or domestic violence.

We may disclose health information to government agencies for activities authorized by law involving oversight of the health care system, government programs, or compliance with applicable laws.

We may disclose health information in response to a court order, administrative proceeding, subpoena, discovery request, or other lawful process when permitted or required by law.

We may disclose health information to law enforcement officials when permitted or required by applicable law.

We may use or disclose health information when necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, consistent with applicable law.

We may disclose health information as authorized by or necessary to comply with workers’ compensation laws and similar programs.

We may disclose health information to organizations involved in organ, eye, or tissue donation and transplantation when permitted by law.

We may disclose health information to coroners, medical examiners, and funeral directors when necessary to perform their legally authorized duties.

We may use or disclose health information for research purposes when permitted by applicable law and when appropriate safeguards are in place.

We may disclose health information for certain specialized government functions, including authorized military, national security, intelligence, protective services, and correctional activities when permitted by law.

If EMPATHRA conducts fundraising activities using PHI, we may contact you regarding fundraising as permitted by law.

You may opt out of receiving fundraising communications where required by law.

Certain uses and disclosures of your PHI generally require your written authorization.

For example, authorization may generally be required for:

• Most uses and disclosures of psychotherapy notes;
• Uses or disclosures for marketing purposes; and
• Disclosures that constitute a sale of PHI.

If we ask you to sign an authorization, you may revoke that authorization in writing at any time to the extent permitted by law.

Revoking an authorization will not affect actions already taken based on the authorization before it was revoked.

Psychotherapy notes maintained separately from the medical record receive special protection under HIPAA.

Except where HIPAA permits otherwise, EMPATHRA generally must obtain your written authorization before using or disclosing psychotherapy notes.

Psychotherapy notes are distinct from information contained in your medical or billing records.

You may not have the same right of access to separately maintained psychotherapy notes that you have to other health information in your medical record.

[EMPATHRA MUST COMPLETE THIS SECTION BASED ON WHETHER IT CREATES, RECEIVES, OR MAINTAINS RECORDS SUBJECT TO 42 CFR PART 2.]

If EMPATHRA maintains records subject to the federal confidentiality requirements for substance use disorder patient records under 42 U.S.C. § 290dd-2 and 42 CFR Part 2, those records may be subject to additional privacy protections.

Where applicable, EMPATHRA will comply with the requirements governing the use and disclosure of Part 2 records, including applicable requirements concerning patient consent and restrictions on the use and disclosure of those records.

[INSERT EMPATHRA’S APPROVED PART 2 LANGUAGE HERE AFTER COMPLIANCE REVIEW.]

You may request access to your medical and billing records maintained by EMPATHRA.

To request access, contact:

[PRIVACY OFFICER / RECORDS CONTACT NAME]
[ADDRESS]
[PHONE]
[EMAIL]

We generally will provide a copy or summary of your health information within the timeframe required by applicable law.

Certain information may be subject to legally permitted limitations or exceptions.

EMPATHRA is required by law to:

• Maintain the privacy and security of your PHI;
• Provide you with this Notice describing our legal duties and privacy practices;
• Follow the terms of the Notice currently in effect;
• Notify affected individuals as required by law if a breach occurs involving unsecured PHI;
• Comply with applicable federal and state privacy laws; and
• Provide you with information about how to exercise your privacy rights.

We will not use or disclose your health information for purposes other than those described in this Notice unless you provide written authorization or the law otherwise permits or requires the use or disclosure.

Federal HIPAA requirements may not be the only privacy laws that apply to your health information.

Certain state laws may provide additional protections for mental health information, psychotherapy records, substance use disorder information, HIV-related information, genetic information, reproductive health information, or other specially protected information.

Where applicable, EMPATHRA will comply with federal and state laws that provide greater privacy protection.

EMPATHRA reserves the right to change the terms of this Notice.

Any revised Notice will apply to all PHI that we maintain, including information created or received before the revised Notice becomes effective, to the extent permitted by law.

The current Notice will be made available upon request and will be posted on our website.

If you have questions about this Notice, want to exercise your privacy rights, or wish to file a privacy complaint with EMPATHRA, please contact:

Privacy Officer: [INSERT NAME/TITLE]
EMPATHRA Mental Health Services
[INSERT ADDRESS]
Phone: [INSERT PHONE NUMBER]
Email: [INSERT PRIVACY EMAIL]

You may also contact the U.S. Department of Health and Human Services, Office for Civil Rights.

U.S. Department of Health and Human Services
Office for Civil Rights

Website: https://www.hhs.gov/ocr/privacy/hipaa/complaints/

Telephone: 1-877-696-6775

You may file a complaint with the Office for Civil Rights if you believe your privacy rights have been violated.

EMPATHRA will not retaliate against you for filing a complaint.

I acknowledge that I have received or have been provided access to EMPATHRA Mental Health Services’ Notice of Privacy Practices.

My signature acknowledges receipt of the Notice. It does not constitute authorization for any use or disclosure of my health information beyond those uses and disclosures permitted by law.

Patient Name: ______________________________________

Signature: _________________________________________

Date: ______________________________________________

If signed by personal representative:

Representative’s Name: ______________________________

Relationship/Authority: ______________________________

Signature: _________________________________________

Date: ______________________________________________

NOTICE EFFECTIVE DATE: [INSERT DATE]

LAST REVISED: [INSERT DATE]

EMPATHRA Mental Health Services