HIPPA Notice of Privacy Practice
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective Date: January 6th, 2026
1. Our Legal Duty
Keystone Psychological Services, LLC. (“we,” “us,” or “our”) 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 currently in effect
PHI includes information that identifies you and relates to your mental health, healthcare services, or payment for those services.
2. Uses and Disclosures of Protected Health Information
a. Treatment
We may use and disclose your PHI to provide, coordinate, or manage your psychological treatment. This may include consultation with other healthcare providers involved in your care, as permitted by law.
b. Payment
We may use and disclose your PHI to obtain payment for services provided to you, including billing insurance companies or communicating with billing services.
c. Health Care Operations
We may use and disclose your PHI for practice operations, such as quality assurance, supervision, licensing, training, and administrative purposes.
3. Uses and Disclosures Requiring Authorization
We will not use or disclose your PHI for purposes other than those described in this Notice without your written authorization, except as required or permitted by law.
You may revoke an authorization in writing at any time, except to the extent that action has already been taken.
4. Special Protections for Psychotherapy Notes
Psychotherapy notes receive special protection under HIPAA. We will not use or disclose psychotherapy notes without your written authorization, except as permitted by law (such as for supervision, training, or as otherwise required by law).
5. Uses and Disclosures Without Authorization
We may disclose PHI without your authorization in certain circumstances, including:
When required by law
For public health activities
To report abuse, neglect, or domestic violence
For health oversight activities
In response to a court order, subpoena, or lawful process
To prevent or lessen a serious threat to health or safety
6. Minor Clients and Parent / Guardian Access to Records
In most cases, a parent or legal guardian is considered the “personal representative” of a minor child and may have the right to access the minor’s Protected Health Information (PHI).
However, there are important exceptions under HIPAA and applicable state law.
Parent / Guardian Access
A parent or legal guardian may generally access a minor’s PHI when:
The parent or guardian has legal authority over the minor, and
The minor did not consent to treatment independently under applicable law, and
No legal or clinical exception applies.
Limitations on Access
Under HIPAA and applicable laws in New Jersey, New York, and Florida, parents or guardians may not have the right to access certain information when:
The minor is legally permitted to consent to their own mental health treatment
The minor received services without parental consent as allowed by law
Disclosure would, in the clinician’s professional judgment, be reasonably likely to cause harm to the minor or the therapeutic relationship
The information consists of psychotherapy notes
A court order, custody agreement, or other legal restriction limits access
When permitted by law, we may use professional judgment to determine whether releasing information is in the best interest of the minor.
Requests for Records
Requests for access to a minor’s records must be submitted in writing. Documentation of legal guardianship or custody may be required. Requests will be handled in accordance with HIPAA and applicable state law.
7. Your Rights Regarding Your PHI
You have the right to:
Access: Inspect or obtain a copy of your PHI
Amend: Request corrections to your PHI
Accounting of Disclosures: Receive a list of certain disclosures
Request Restrictions: Ask for limits on how your PHI is used or disclosed (we are not required to agree to all requests)
Confidential Communications: Request communication by alternative means or at alternative location
Paper Copy: Receive a paper copy of this Notice at any time
File a Complaint: File a complaint if you believe your privacy rights have been violated
You will not be retaliated against for filing a complaint.
8. Complaints
If you believe your privacy rights have been violated, you may file a complaint with:
Dr. Ingrid Diaz, Keystone Psychological Services, LLC.
Phone: (732) 718-4873 Email: dr.diaz@keystonepsych.com
You may also file a complaint with the U.S. Department of Health and Human Services:
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775
9. State Law Considerations
We comply with applicable privacy laws and professional regulations in:
New Jersey
New York
Florida
When state law provides greater privacy protections than federal law, we follow state law.
10. Changes to This Notice
We reserve the right to change this Notice. Any changes will apply to all PHI we maintain and will be made available in our office and on our website, if applicable.
11. Contact Information
If you have questions about this Notice or your privacy rights, please contact:
Dr. Ingrid Diaz
Keystone Psychological Services, LLC.
Email: dr.diaz@keystonepsych.com
Phone: (732) 718-4873
Location: 1200 US-22 #2000, Bridgewater, NJ 08807
Licensed in: New Jersey, New York, and Florida