Notice of Privacy Practices

Effective September 16, 2026.

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.

Who this notice covers

This notice applies to Heart Space Clinical Psychology and to Dr. Neha Pancholi-Patel, Psy.D., Licensed Clinical Psychologist, referred to below as “the practice” or “we”. The practice is required by law to protect the privacy of your protected health information, to give you this notice of our legal duties and privacy practices, and to follow the terms of the notice currently in effect.

How we may use and disclose your health information

Treatment

We may use your health information to provide, coordinate or manage your psychological care. With your written authorization, we may share information with other providers involved in your care, such as a physician, psychiatrist, dietitian or school.

Payment

We may use and disclose your health information to obtain payment for services. Because the practice is private pay and out of network, this ordinarily means preparing a superbill at your request that you submit to your own insurer. That superbill will contain a diagnosis and service codes.

Health care operations

We may use your health information for activities necessary to run the practice, such as quality review, clinical consultation, supervision and business management.

Uses and disclosures that require your written authorization

Most uses and disclosures of psychotherapy notes, any use or disclosure for marketing purposes, and any sale of your health information require your written authorization. Other uses and disclosures not described in this notice will be made only with your written authorization. You may revoke an authorization in writing at any time, except to the extent we have already acted in reliance on it.

Uses and disclosures that do not require your authorization

State and federal law permit or require us to disclose health information without your authorization in limited circumstances, including:

When required by law. We will disclose information when federal, state or local law requires it.
Suspected abuse or neglect. We are mandated to report suspected abuse or neglect of a child, an elderly person or an incapacitated adult to the appropriate authorities.
Serious threat to health or safety. If you communicate a serious threat of physical harm to an identifiable person, or if there is a serious and imminent risk of harm to you, we may disclose information as necessary to prevent that harm, including to potential victims and to law enforcement.
Judicial and administrative proceedings. We may disclose information in response to a court order, and in response to a subpoena or discovery request only where the applicable legal requirements have been met.
Health oversight. We may disclose information to a health oversight agency for activities authorized by law, such as a licensing board investigation.
Public health activities. We may disclose information to public health authorities as permitted by law.
Workers’ compensation. We may disclose information as authorized by workers’ compensation laws.
Coroners, medical examiners and funeral directors. We may disclose information as permitted by law.
Business associates. We may share information with vendors who perform services for the practice, such as our electronic health record and telehealth platform. Each is bound by a written agreement to protect your information.

Your rights

To inspect and copy. You may request access to your record. We may deny access to psychotherapy notes, and we may deny access in other limited circumstances; where the law provides for review of a denial, you may request that review.
To request an amendment. If you believe information in your record is incorrect or incomplete, you may ask us to amend it. We may deny the request, and if we do we will explain why in writing and you may submit a statement of disagreement.
To an accounting of disclosures. You may request a list of certain disclosures we have made of your health information.
To request restrictions. You may ask us to limit how we use or disclose your information. We are not required to agree, except that we must agree to withhold information from a health plan where you have paid for the service in full out of pocket.
To request confidential communications. You may ask us to contact you in a particular way or at a particular address or number.
To a paper copy. You may request a paper copy of this notice at any time, even if you agreed to receive it electronically.
To be notified of a breach. We will notify you if a breach occurs that may have compromised the privacy or security of your information.

To exercise any of these rights, contact the practice in writing at hello@heartspaceclinicalpsychology.com.

Our duties

We are required by law to maintain the privacy of your health information, to provide you with this notice, and to abide by its terms. We reserve the right to change this notice and to make the revised notice effective for information we already hold as well as information we receive in the future. The current notice will always be posted on this page, with its effective date.

Complaints

If you believe your privacy rights have been violated, you may complain to the practice at hello@heartspaceclinicalpsychology.com or (571) 384-8823. You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at hhs.gov/ocr/complaints. You will not be retaliated against for filing a complaint.