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.
I. My pledge regarding health information
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. It describes the ways in which I may use and disclose health information about you, your rights regarding the health information I keep about you, and certain obligations I have regarding the use and disclosure of your health information.
I am required by law to: make sure that protected health information ("PHI") that identifies you is kept private; give you this Notice of my legal duties and privacy practices with respect to health information; follow the terms of the Notice currently in effect; and notify you following a breach of unsecured protected health information, as required by law.
I can change the terms of this Notice, and such changes will apply to all information I have about you. A copy of this Notice is available to you upon request.
II. How I may use and disclose health information about you
For treatment, payment, or health care operations. Federal privacy regulations allow health care providers who have a direct treatment relationship with you to use or disclose your protected health information, without written authorization, to carry out treatment, payment, or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. For example, if I were to consult with another licensed health care provider about your condition, I would be permitted to use and disclose your protected health information in order to assist in the diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard, because health care providers need access to the full record in order to provide quality care. The word "treatment" includes, among other things, the coordination and management of health care with a third party, consultations between health care providers, and referrals of a client for health care from one provider to another.
Lawsuits and disputes. If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. Certain uses and disclosures require your authorization
Psychotherapy notes. I do keep "psychotherapy notes" as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your authorization unless the use or disclosure is: for my use in treating you; for my use in training or supervising mental health practitioners; for my use in defending myself in legal proceedings instituted by you; for use by the Secretary of Health and Human Services to investigate my compliance with HIPAA; required by law, and limited to the requirements of such law; required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes; required by a coroner performing duties authorized by law; or required to help avert a serious threat to the health and safety of others.
Marketing purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.
IV. Certain uses and disclosures do not require your authorization
Subject to certain limitations in the law, I can use and disclose your PHI without your authorization for the following reasons:
- When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
- For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone's health or safety.
- For health oversight activities, including audits and investigations.
- For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an authorization from you before doing so.
- For law enforcement purposes, including reporting crimes occurring on my premises.
- To coroners or medical examiners, when such individuals are performing duties authorized by law.
- For research purposes, including studying and comparing the mental health of clients who received one form of therapy versus those who received another form of therapy for the same condition.
- For specialized government functions, including ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or helping to ensure the safety of those working within or housed in correctional institutions.
- For workers' compensation purposes. Although my preference is to obtain an authorization from you, I may provide your PHI in order to comply with workers' compensation laws.
- For appointment reminders and health-related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me, or to tell you about treatment alternatives or other health care services or benefits that I offer.
V. Certain uses and disclosures require you to have the opportunity to object
Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. Your rights with respect to your PHI
The right to request limits on uses and disclosures of your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say "no" if I believe it would affect your health care.
The right to request restrictions for out-of-pocket expenses paid for in full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or service that you have paid for out-of-pocket in full.
The right to choose how I send PHI to you. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
The right to see and get copies of your PHI. Other than "psychotherapy notes," you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.
The right to get a list of the disclosures I have made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an authorization. I will respond to your request within 60 days. The list will include disclosures made in the last six years unless you request a shorter time. I will provide the list at no charge, but if you make more than one request in the same year, I may charge a reasonable, cost-based fee for each additional request.
The right to correct or update your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. I may say "no" to your request, but I will tell you why in writing within 60 days of receiving your request.
The right to get a paper or electronic copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this Notice by email. Even if you have agreed to receive this Notice via email, you also have the right to request a paper copy of it.
VII. Questions or complaints
If you have questions about this Notice, wish to exercise any of the rights described above, or believe your privacy rights have been violated, you may contact Dr. Samantha Green at (424) 237-8295 or by mail at the address listed above. You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. You will not be retaliated against for filing a complaint.
NOTICE TO CONSUMERS: The Department of Consumer Affairs' Board of Psychology receives and responds to questions and complaints regarding the practice of psychology. If you have questions or complaints, you may contact the Board on the internet at www.psychology.ca.gov, by emailing bopmail@dca.ca.gov, by calling 1-866-503-3221, or by writing to the following address: Board of Psychology, 1625 North Market Boulevard, Suite N-215, Sacramento, California 95834.