Print this form, sign it, and bring it to your first appointment.

Richard J. DioGuardi, Ph.D.

Licensed Psychologist | New York State License No. 016999

600 Mamaroneck Avenue, Suite 400, Harrison, NY 10528 • (914) 233-7177 • rjd@drdioguardi.com

HIPAA Notice of Privacy Practices

Acknowledgment & Consent to Treatment

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.

1. Our Commitment to Your Privacy

Dr. Richard J. DioGuardi, Ph.D. ("the Practice") is committed to protecting the privacy of your health information. This Notice describes the Practice's legal duties and privacy practices with respect to your Protected Health Information ("PHI"), as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations.

2. How We May Use and Disclose Your Health Information

Treatment. We may use and disclose your PHI to provide, coordinate, or manage your mental health treatment and related services. For example, we may share information with other treating clinicians, physicians, or specialists involved in your care, with your written authorization.

Payment. We may use and disclose your PHI to obtain payment for services rendered. This may include submitting claims to insurance companies or providing billing information to you directly. Note: Dr. DioGuardi is an out-of-network provider. A superbill may be provided upon request for reimbursement purposes.

Healthcare Operations. We may use and disclose your PHI for internal practice operations, including quality assessment, training, and administrative functions necessary to run the Practice.

Required by Law. We may disclose your PHI when required to do so by federal, state, or local law, including mandatory reporting obligations.

3. Special Circumstances — Disclosures Without Your Authorization

New York law and professional ethics require or permit disclosure of confidential information in the following limited circumstances:

Imminent danger to self or others: If you present a serious and imminent threat of harm to yourself or an identifiable third party, we may disclose information to prevent that harm.
Child or vulnerable adult abuse: We are mandated reporters under New York law and must report suspected abuse or neglect of a child or vulnerable adult to the appropriate authorities.
Court order: We may disclose records if ordered to do so by a court of competent jurisdiction.
Medical emergency: We may disclose information to emergency personnel if necessary to address a serious medical emergency.

All other disclosures require your written authorization, which you may revoke at any time in writing.

4. Your Rights Regarding Your Health Information

Right to inspect and copy your PHI (certain exceptions may apply).
Right to request an amendment to your PHI if you believe it is inaccurate or incomplete.
Right to an accounting of disclosures made outside of treatment, payment, and operations.
Right to request restrictions on how your PHI is used or disclosed (we are not required to agree to all requests).
Right to receive confidential communications by alternative means or at an alternative location.
Right to a paper copy of this Notice upon request.
Right to file a complaint with the Practice or with the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. You will not be penalized for filing a complaint.

5. Telehealth & Electronic Communications

Sessions conducted via telehealth platforms use HIPAA-compliant, encrypted technology. Unencrypted email and standard text messaging are not considered secure methods for transmitting PHI. By communicating with the Practice via email or text, you acknowledge and accept the associated risks.

6. Minors

For clients under 18, a parent or legal guardian must provide consent for treatment. Consistent with New York law and sound clinical practice, Dr. DioGuardi may share general progress information with parents or guardians while maintaining the confidentiality of specific session content in order to support the therapeutic relationship.

7. Changes to This Notice

The Practice reserves the right to change this Notice and to make the revised Notice effective for health information already maintained, as well as information received in the future. The current Notice will be posted in the office and on the Practice website.

8. Contact Information

To exercise any of your rights, request a copy of your records, or file a complaint, please contact:

Richard J. DioGuardi, Ph.D.
600 Mamaroneck Avenue, Suite 400
Harrison, NY 10528
(914) 233-7177 • rjd@drdioguardi.com

Acknowledgment & Consent

By signing below, I acknowledge that I have received, read, and understood the HIPAA Notice of Privacy Practices of Richard J. DioGuardi, Ph.D. I consent to the use and disclosure of my (or my child's) health information as described in this Notice for the purposes of treatment, payment, and healthcare operations. I understand that I may revoke this consent in writing at any time, except to the extent that action has already been taken in reliance on it.

Patient / Guardian Printed Name

Relationship to Patient (if signing on behalf of a minor)

Signature

Date

Patient Date of Birth

Please print, sign, and bring this completed form to your first appointment.
A copy will be retained in your clinical record. If you have any questions before your first session, please call (914) 233-7177.