Notice of Privacy Practices
Effective Date: July 25, 2026
Your Health Information, Your Rights, and Our Responsibilities
This notice explains how health information about you may be used or disclosed, how you may access that information, and the responsibilities of Kelsey Psychological Services, PLLC.
This notice applies to protected health information created or maintained by Kelsey Psychological Services, PLLC in connection with psychological treatment, evaluations, consultation, billing, and related healthcare activities.
Your Rights
Access your records
You may request an electronic or paper copy of the health and billing records maintained about you, subject to certain legal limitations. You may also request that the practice provide a summary instead of copies.
The practice will ordinarily respond within the time required by applicable law. A reasonable, cost-based fee may apply when permitted.
Psychotherapy notes receive additional legal protection and are generally not included in the same right of access as the remainder of the clinical record.
Ask for a correction
You may ask the practice to correct information that you believe is inaccurate or incomplete.
The practice may deny the request in certain circumstances but will provide an explanation in writing when required.
Request confidential communications
You may ask the practice to contact you in a particular way or at a particular address. For example, you may request communication through the secure portal rather than voicemail.
Reasonable requests will be accommodated.
Ask for restrictions
You may ask the practice not to use or disclose particular health information for treatment, payment, or practice operations. The practice is not always legally required to agree, although agreed-upon restrictions will be followed unless disclosure is needed for emergency treatment or otherwise required by law.
When you pay for a service completely out of pocket, you may request that information about that service not be disclosed to your health insurer for payment or healthcare operations. The practice will honor that request unless disclosure is required by law.
Receive an accounting of certain disclosures
You may request a list of certain disclosures of your health information made during the legally permitted look-back period.
The accounting generally does not include routine disclosures made for treatment, payment, practice operations, or disclosures made at your direction.
Receive a copy of this notice
You may request a paper or electronic copy of this notice at any time, even when you previously agreed to receive it electronically.
Choose someone to act for you
A legally authorized personal representative may exercise privacy rights on your behalf. The practice may request documentation establishing that person’s authority.
File a complaint
You may contact the practice if you believe your privacy rights have been violated.
You may also submit a complaint to the U.S. Department of Health and Human Services Office for Civil Rights. Kelsey Psychological Services will not retaliate against you for raising a concern or filing a complaint.
These rights and provider responsibilities are part of the current HHS model notice for covered healthcare providers.
Your Choices
In certain circumstances, you may tell the practice whether or how your information may be shared, including disclosures to:
Family members
Friends involved in your care
Individuals assisting with payment
Disaster-relief organizations
When you cannot communicate your preference, information may be disclosed when legally permitted and reasonably believed to be in your best interest or necessary to reduce a serious and imminent threat.
Your written authorization will generally be required for:
Marketing activities not otherwise permitted by law
Sale of protected health information
Most uses or disclosures of psychotherapy notes
Disclosures that are not otherwise permitted by law
You may revoke an authorization in writing, although the revocation will not undo actions already taken in reliance on the authorization.
How the Practice May Use or Disclose Information
Treatment
The practice may use health information to provide, coordinate, or manage your care. With appropriate permission or when otherwise legally permitted, information may be shared with other professionals involved in your treatment.
Practice operations
Information may be used to operate the practice, maintain records, conduct quality-improvement activities, schedule appointments, communicate with you, maintain security, and support administrative functions.
Payment
Information may be used to collect payment, prepare invoices or superbills, process card payments, determine balances, or communicate with a health plan when authorized or legally permitted.
Evaluations requested by you or another party
When you participate in a psychological, disability, forensic, or fitness-for-duty evaluation, information may be used and disclosed according to the purpose of the evaluation, applicable authorization, referral agreement, court order, or law.
Evaluation services may involve different confidentiality expectations than therapy. Those expectations, including who is entitled to receive the report, will be explained before the evaluation begins.
Public health and safety
The practice may disclose information when permitted or required for purposes such as:
Reporting suspected abuse or neglect
Preventing or reducing a serious threat to health or safety
Reporting certain public-health matters
Complying with legally authorized health-oversight activities
Legal and governmental requirements
Information may be disclosed when required or permitted in connection with:
Court or administrative orders
Valid legal process
Workers’ compensation matters
Law-enforcement requests
Professional licensing or health-oversight activities
Military or other special governmental functions
Coroners, medical examiners, or funeral directors
Other disclosures required by federal or state law
Additional conditions and legal protections may apply before any disclosure is made.
Research
Information may be used or disclosed for legally authorized research only when all applicable privacy requirements have been satisfied.
Substance-Use-Disorder Records
To the extent that the practice creates or maintains records protected by 42 C.F.R. Part 2, those records receive additional legal protections. Such records generally may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you without your written consent or an appropriate court order and subpoena.
The current HHS provider model incorporates Part 2 protections into HIPAA notices beginning in 2026.
Our Responsibilities
Kelsey Psychological Services is required to:
Protect the privacy and security of protected health information
Follow the privacy practices described in the current notice
Provide you with a copy of the notice
Notify affected individuals when a reportable breach compromises information
Obtain written authorization before using or disclosing information when authorization is legally required
The practice will not use or disclose your information other than as described in this notice or otherwise permitted by law without your written authorization.
Changes to This Notice
The practice may revise this notice. A revised notice may apply to information already maintained as well as information received in the future.
The current version will be available on the practice website and upon request.
Questions or Complaints
Privacy Contact: Matthew R. Kelsey, Psy.D.
Kelsey Psychological Services, PLLC
Email: info@kelseypsych.com
Telephone: (646) 284-2673
Mailing address: 6688 Nolensville Rd, Brentwood, TN 37027
Complaints may also be filed with the U.S. Department of Health and Human Services, Office for Civil Rights. The practice will not retaliate against anyone for exercising privacy rights or making a complaint.