Notice of Privacy Practices
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.
Dolomite Child & Adult Psychiatry, PLLC
Effective September 26 2026
Contact and scope
This notice applies to the practice and its workforce. For a copy, a privacy question, a rights request, or a complaint, contact Mya Shaikh, PMHNP-BC, Privacy Officer, at (312) 426-2705 or info@dolomitepsych.com. You may also contact us through the approved patient portal. Call for a secure submission method or mailing instructions; do not include detailed health information in ordinary email.
Our responsibilities
We must protect your health information, provide this notice of our duties and practices, follow the notice currently in effect, and notify affected people following a breach of unsecured protected health information when the law requires notice.
Illinois mental-health confidentiality law may provide stronger protections than HIPAA. We apply those protections. A HIPAA permission for treatment, payment, or operations does not by itself override an Illinois consent requirement. We obtain specific written consent when required or document the applicable legal exception.
Treatment payment and practice operations
For treatment, we use information to assess symptoms, discuss medication options, coordinate your care, and document services. For example, your clinician may review medication history with a treating professional when a valid consent or legal exception permits that exchange.
For payment, we may use and disclose the information legally needed to verify benefits, submit a claim, or resolve a bill. For example, a claim may identify a diagnosis and service. Additional consent is obtained where Illinois law requires it.
For health care operations, we may review records for quality, safety, training, compliance, and administration. For example, authorized staff may review documentation to resolve an error. Approved business associates may support these functions under required contractual and legal safeguards. Staff access is limited by job duties.
We may contact you about appointments, treatment alternatives, and health-related services associated with your care, consistent with your confidential communication preferences and applicable law. Office SMS remains optional and administrative under the separate SMS terms.
Other uses and disclosures
The following categories apply only when federal law, Illinois law, and any special record protections permit or require the specific disclosure. We limit information to the lawful purpose and obtain consent when required.
- Required reports and public health: reports such as suspected abuse or neglect, reportable conditions, medication adverse events, or product recalls, within the limits of the applicable reporting law.
- Safety: information necessary to address a serious threat or emergency under the applicable legal standards. Your clinician evaluates the circumstances and permitted recipients.
- Oversight and compliance: information to authorized agencies for lawful audits, investigations, licensure, or inspection, including HHS review of our compliance.
- Legal process and law enforcement: only when the particular request satisfies all applicable requirements. A subpoena alone is not automatically sufficient for Illinois mental-health records. We may require valid written consent or the necessary court order and other process.
- Other legally authorized purposes: qualifying workers' compensation matters, certain specialized government functions, coroners or medical examiners, funeral directors, and organ procurement, only to the extent permitted by the laws protecting the records.
- Research: only with a valid authorization or another applicable legal basis and all required safeguards. Generic HIPAA research permissions do not displace Illinois mental-health protections.
Family members and personal representatives
We verify a person's legal authority before allowing that person to exercise your rights. Family involvement is based on your choices and the law. Being an emergency contact, paying a bill, or sharing a phone does not automatically confer access to your records. Limited emergency or incapacity disclosures may be permitted where the law's conditions are met.
Children and adolescents have privacy rights under Illinois law. We assess age, who can consent to the service, legal authority, the minor's views, and the applicable access rules. We do not promise parents unrestricted access or promise minors absolute secrecy.
Information requiring additional permission
Most uses and disclosures of separately maintained psychotherapy notes, marketing uses requiring authorization, and sales of protected health information require written authorization. We do not sell patient health information or use the office texting program for marketing. Other uses not described in this notice require your written authorization unless the law allows or requires them.
You may revoke an authorization in writing by contacting the Privacy Officer. Revocation is prospective and does not undo action already taken in reliance on it. Illinois disclosure consents must identify their scope and calendar expiration date.
Substance use disorder records
Some substance use disorder records are protected by 42 CFR Part 2. Not every reference to substance use is a Part 2 record. If we receive or maintain protected Part 2 records, additional restrictions apply.
Records from a Part 2 program, and testimony describing their contents, cannot be used or disclosed in civil, criminal, administrative, or legislative proceedings against you without your specific written consent or a qualifying court order after notice and an opportunity to be heard. A court order authorizing disclosure must also be accompanied by a subpoena or other legal requirement compelling disclosure before we disclose the requested record.
A valid Part 2 consent may permit future treatment, payment, and health care operations disclosures. A covered entity or business associate receiving records under that consent may redisclose them as HIPAA allows, subject to Part 2's restrictions on proceedings against you and any stricter applicable law. Separately maintained SUD counseling notes require their own consent when applicable. A general treatment consent or optional SMS choice does not supply these permissions.
We do not use patient information for fundraising under this notice. If this practice changes, we will update the notice and provide required choices, including a clear opportunity to decline fundraising using Part 2 information before that use.
Your rights to records and corrections
Access: You may ask to inspect or receive a paper or electronic copy of information in the designated record set, including medical and billing records. Contact the Privacy Officer or use the patient portal. We verify identity without unreasonable barriers and provide the requested format when readily producible. We normally act within 30 calendar days, sooner if applicable law requires. If legally permitted, one extension of up to 30 days requires a written reason and completion date within the original period.
Any permitted fee is reasonable and cost-based; ask for an estimate. Inspection is not subject to a copying fee. Certain narrow exceptions apply, such as separately maintained psychotherapy notes under HIPAA. We review any additional Illinois access rights. If we deny access, we explain the basis, any review rights, and how to complain in writing. We do not withhold access because you owe a treatment balance.
Correction: You may request an amendment of incomplete or inaccurate information. We ordinarily respond within 60 days; one permitted extension of up to 30 days requires written notice. A denial explains the reason and your right to submit a statement of disagreement. Illinois law also allows a statement concerning disputed or new information to be added to the record and to accompany the disputed part when disclosed.
Your other privacy rights
Confidential communications: You may request a different contact method or location. We accommodate reasonable requests. Tell us whether messages, voicemail, shared phone access, mailed material, or a caregiver's portal access could expose private information.
Restrictions: You may ask us to limit uses or disclosures for treatment, payment, or operations. We are not required to agree to every request. We must honor a request not to disclose a service to your health plan for payment or operations when you or someone other than the plan pays for that service in full out of pocket, unless disclosure is required by law. Ask before a claim is sent so we can arrange the restriction.
Accounting: You may request a list of disclosures subject to HIPAA accounting for up to the six years before your request. This generally excludes treatment, payment, operations, disclosures to you, and disclosures made under your authorization, as well as other legal exclusions. We respond within 60 days; one permitted 30-day extension requires written notice. The first accounting in a 12-month period is free. We explain any permitted fee for an additional request and allow you to withdraw or narrow it.
Notice: You may request a paper copy at any time, even if you previously accepted electronic delivery. The current notice is available by contacting us and at https://www.dolomitepsychiatry.com/notice-of-privacy-practices.
Complaints without retaliation
You may complain to Mya Shaikh, PMHNP-BC, Privacy Officer, by telephone at (312) 426-2705, through the approved patient portal, or by email to info@dolomitepsych.com. Describe your concern and a safe way to reach you. A particular form is not required. Ask for a secure way to provide sensitive details.
You may also complain to the U.S. Department of Health and Human Services Office for Civil Rights at https://www.hhs.gov/hipaa/filing-a-complaint/index.html, by calling 1-800-368-1019, or by writing to Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201. Complaints ordinarily must be filed within 180 days of when you knew of the issue; OCR may extend this for good cause. We will not retaliate or require you to waive privacy rights to receive care.
Changes to this notice
We may revise this notice and make the revised terms apply to information we already hold as well as new information, to the extent the law permits. We will make the updated notice available upon request and on our website, and at any physical service location. The effective date appears on the first page of the notice.
Contact: (312) 426-2705 | info@dolomitepsych.com