NOTICE OF PRIVACY PRACTICES (HIPAA)


Shared Smile Behavioral Health PLLC

Effective Date: April 2, 2026

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

Your Rights

You have the right to:

  • Get a copy of your medical record (electronic or paper)
  • Request corrections to your medical record
  • Request confidential communication (e.g., different phone or email)
  • Ask us to limit what we use or share
  • Get a list of those with whom we’ve shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you (e.g., medical power of attorney)
  • File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in how we use and share your information. You can tell us your preferences for:

  • Sharing information with family, friends, or others involved in your care
  • Contacting you for appointment reminders
  • Using your information for certain communications

We will not share your information for marketing purposes without your written permission.

Our Uses and Disclosures

We may use and share your information in the following ways:

Treatment

We use your information to provide, coordinate, and manage your mental health care.

Payment

As a cash-pay practice, we do not bill insurance. However, we may provide documentation to you for reimbursement purposes if requested.

Healthcare Operations

We use your information to run our practice, improve care, and ensure quality.

Legal Requirements

We may disclose information when required by law, including:

  • Reporting abuse or neglect
  • Preventing serious threats to health or safety
  • Complying with court orders

Our Responsibilities

We are required by law to:

  • Maintain the privacy and security of your protected health information (PHI)
  • Notify you promptly if a breach occurs
  • Follow the duties and privacy practices described in this notice
  • Not use or share your information other than as described unless you authorize us

Your Rights to File a Complaint

If you believe your rights have been violated, you may:

  • Contact us directly at:
    Email: [email protected]
    Phone: 703-755-0953
  • File a complaint with the U.S. Department of Health and Human Services:
    https://www.hhs.gov/hipaa/filing-a-complaint

You will not be penalized for filing a complaint.

Changes to This Notice

We reserve the right to change this notice. Updated versions will be posted on our website with a new effective date.

Contact Information

Shared Smile Behavioral Health PLLC
Serving Virginia & Maryland (Telehealth)

Email: [email protected]
Phone: 703-755-0953
Website: www.sharedsmilebh.com

View Services in Maryland View Services in Virginia

Acknowledgment of Receipt

By engaging in services, you acknowledge that you have received or had access to this Notice of Privacy Practices.