Shane Becker, LCSW | Private Practice — New York State

Effective Date: 3/21/2026 | Last Revised: 3/21/2026

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Legal Duties

I am required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended by the Health Information Technology for Economic and Clinical Health (HITECH) Act, to maintain the privacy of your protected health information (PHI), to provide you with this Notice of Privacy Practices, and to abide by the terms of this Notice currently in effect.

As a licensed psychotherapist practicing in New York State, I am also bound by New York State Mental Hygiene Law, New York Education Law, and related regulations that may provide additional privacy protections beyond those required by federal law. Where state law is more protective of your privacy, state law governs.

Protected Health Information (PHI) includes any information that could identify you and relates to your past, present, or future physical or mental health condition; the provision of health care to you; or payment for that health care.

How I May Use and Disclose Your Information

In general, I will not use or disclose your health information without your written authorization, except as described below. If you give me authorization to use or disclose your health information, you may revoke that authorization in writing at any time.

For Treatment

I may use and disclose your PHI to provide, coordinate, or manage your mental health treatment. For example, I may share information with other treating clinicians (such as your psychiatrist or primary care physician) involved in your care, with your written authorization or as otherwise permitted by law.

For Payment

I may use and disclose your PHI so that I or others may bill and receive payment for services provided to you. For example, I may submit claims to your health insurance company including information about the services you received.

For Health Care Operations

I may use and disclose your PHI for health care operations necessary to run my practice, such as quality assessment, professional peer review, licensing compliance, training, and business management functions.

As Required by Law

I will disclose your PHI when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety

I may use and disclose your PHI when I believe it is necessary to prevent or lessen a serious and imminent threat to the health or safety of you or another person. This includes situations where I am required by law to report to appropriate authorities.

Mandatory Reporting

New York law requires me to report in the following circumstances:

∙ Child abuse or neglect: I am required to report reasonable suspicion of child abuse or maltreatment to the New York State Central Register (SCR).

∙ Adult abuse: I am required to report suspected abuse or neglect of vulnerable adults in certain circumstances.

∙ Duty to protect: If a patient makes a credible threat of serious and imminent harm against an identifiable third party, I may be required to take steps to protect that person, which may include disclosure.

∙ Judicial or administrative proceedings: I may disclose your PHI in response to a valid court order or subpoena, subject to applicable legal protections for mental health records.

∙ Public health activities: Disclosures may be made to authorized public health authorities for activities such as preventing or controlling disease.

∙ Workers’ compensation: I may release records as authorized and required by workers’ compensation laws.

Business Associates

I may share your PHI with business associates (such as billing services or electronic health record platforms) who perform services on my behalf. These entities are required by law to protect your information and may only use it for the purposes for which they were engaged.

Other Uses and Disclosures

All other uses and disclosures of your PHI not described in this Notice will be made only with your written authorization. This includes marketing communications, sale of your PHI, disclosures to employers, and most disclosures of psychotherapy notes.

Special Protections for Mental Health Information

New York State provides stronger privacy protections for mental health records than general HIPAA requirements. Your mental health treatment records receive heightened protection under state law.

Psychotherapy Notes

Psychotherapy notes — my personal notes recording the contents of conversations during counseling sessions — are subject to special protection under HIPAA. I will not use or disclose psychotherapy notes without your specific written authorization, except in limited circumstances:

∙ Use by me for your treatment

∙ Training of mental health professionals under my supervision

∙ Defense of a legal action brought by you against me

∙ An oversight audit of my practice

∙ As required to avert a serious and imminent threat to health or safety

∙ As required by law (e.g., a court order)

New York State Mental Hygiene Law

Under New York Mental Hygiene Law § 33.13, clinical records maintained by licensed mental health practitioners are confidential and may not be disclosed without your written consent, except in specific circumstances defined by statute.

HIV/AIDS-Related Information

Under New York Public Health Law Article 27-F, HIV-related information receives special confidentiality protections and generally may not be disclosed without your written authorization on a specific HIV disclosure form.

Substance Use Disorder Treatment Records

If applicable, records relating to substance use disorder treatment may be subject to additional federal protections under 42 C.F.R. Part 2, which restricts disclosure without your written consent except in specific circumstances.

Your Privacy Rights

You have the following rights regarding your health information. To exercise any of these rights, please submit a written request using the contact information below.

Right to Access

You have the right to inspect and obtain a copy of your PHI in a designated record set. I will respond within 30 days. A reasonable fee may apply for copies.

Right to Amend

You may request that I amend your PHI if you believe it is inaccurate or incomplete. I may deny the request under certain circumstances but will provide a written explanation.

Right to an Accounting of Disclosures

You may request a list of disclosures of your PHI that I have made in the prior six years, other than disclosures made for treatment, payment, or health care operations.

Right to Request Restrictions

You may ask me to restrict how I use or disclose your PHI. I am not always required to agree, but I must comply if the restriction relates to a disclosure to a health plan for services you paid for in full out of pocket.

Right to Confidential Communications

You may request that I communicate with you by alternative means or at an alternative location (e.g., a different phone number or address) if disclosure at your regular contact information would put you at risk.

Right to a Paper Copy of This Notice

You have the right to receive a paper copy of this Notice at any time, even if you agreed to receive it electronically. Please contact me to request one.

How to File a Complaint

If you believe your privacy rights have been violated, you may file a complaint with me directly or with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR). You will not be retaliated against for filing a complaint.

U.S. Department of Health and Human Services — Office for Civil Rights

Website: www.hhs.gov/ocr/complaints

Phone: 1-800-368-1019 (TDD: 1-800-537-7697)

Mail: Hubert H. Humphrey Building, 200 Independence Ave., S.W., Washington, D.C. 20201

You may also file a complaint with the New York State Office of Mental Health or the New York State Education Department, Office of the Professions, as applicable.

Changes to This Notice

I reserve the right to change this Notice of Privacy Practices at any time, including making changes effective for health information I already hold about you. The current Notice will always be posted on this website and is available upon request. If I make a material change, I will provide you with a revised Notice at your next appointment or by other means as required by law.

Contact Information

Shane Becker, LCSW

Brooklyn, NY 11226

Phone: 914-340-4069

Email: shanebeckerlcsw@gmail.com

This Notice of Privacy Practices is provided in compliance with HIPAA (45 C.F.R. §164.520) and New York State law.

© 2026 Shane Becker, LCSW