Varad Privacy Patient Rights Form | Varad Integrative Psychiatry Clinic For Mental Health And Holistic Wellness Center Bellevue


This notice summarizes how the NeuroPsych Program may use or disclose your medical information and your rights provided under the new Health Insurance Portability and Accountability Act (HIPAA).

You have the right to:

  • Obtain a copy of the Notice of Privacy Practices upon request. This document explains your privacy rights and how your information may be used by NeuroPsych Program.
  • Request a restriction on certain uses and disclosures of your information. We are not required by law to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
  • Inspect and request a copy of your health record. We may deny your request under very limited circumstances. If you are denied access to health care information, you may request that the denial be reviewed by another health care professional chosen by someone on our health care team. We will abide by the outcome of that review. There is a fee for this service.
  • Request an amendment to your health record. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. Also, we may deny your request if the information was not created by our health care team, is not part of the information kept by our facility, is not part of the information which you would be permitted to inspect and copy, and if the information is accurate and complete. Please note that even if we accept your request, we are not required to delete any information from your health care record.
  • Obtain an accounting of disclosures of your health information. The accounting will only provide information about disclosures made for purposes other than treatment, payment or health care.
  • Request communication of your health information by alternative means or locations. Your request must be in writing, and NeuroPsych Program may deny your request if it is not practical.
  • Provide the hospital with a signed authorization. This document will be used to disclose your health care information for other reasons besides treatment and payment.
  • Revoke your authorization. You may request in writing to revoke your authorization to use or disclose health care information except to the extent that action has already been taken.
  • Complain about any aspect of our health care information practices to us or to the Department of Health and Human Services or the United States. You can file a complaint with us and expect an investigation and explanation by calling or writing: NeuroPsych Program,14595 Bel Red Rd., Bldg. D, Suite 201, Bellevue WA 98007. You can file a complaint to the Dept. of Health and Human Services by addressing your written complaint to: Secretary, Dept. of Health and Human Services.

NeuroPsych Program Obligations to you are:

  • To provide written notice of how the NeuroPsych Program uses and discloses your health care information. This notice of Privacy Practices will explain your privacy rights.
  • That your health care information will not be used for marketing activities.
  • That only the minimum necessary information will be used and disclosed except for treatment activities.
  • To protect your health care information with Business Associates. The NeuroPsych Program will have written agreements with vendors and suppliers who require your health information.
  • To use and disclose your protected health care information for treatment, payment, hospital, and to satisfy state, federal, law enforcement and oversight reporting requirements.

I acknowledge receipt of NeuroPsych Program Privacy & Patient Rights.

By signing below, I hereby consent to the above agreement.

Patient/Guardian Signature