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.

Our Responsibilities
Action Potential Neuropsychological Services is required by law to:
• Maintain the privacy of your protected health information (PHI)
• Provide you with this Notice of Privacy Practices
• Follow the terms of this notice

Uses and Disclosures of Protected Health Information
We may use and disclose your PHI for the following purposes:

Treatment
To provide, coordinate, or manage your psychological or neuropsychological care.

Payment
To obtain payment for services, including submitting claims or providing documentation for insurance reimbursement when authorized.

Healthcare Operations
For practice operations such as quality assessment, training, licensing, or administrative purposes.

Legal or Safety Requirements
We may disclose PHI when required by law, including mandatory reporting, court orders, or to prevent serious harm to you or others.

Uses and Disclosures Requiring Authorization
Uses and disclosures of PHI not described above require your written authorization. You may revoke authorization in writing at any time.

Your Rights
You have the right to:
• Access and obtain copies of your records
• Request corrections to your records
• Request restrictions on certain uses or disclosures
• Request confidential communications
• Receive an accounting of disclosures
• Receive a copy of this notice

Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint.

Contact Information
For questions or concerns regarding this Notice, contact:
Dr. Elise Gagnon Pilchak, Psy.D., LP
Action Potential Neuropsychological Services
[Email Address]
[Phone Number]