NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND  DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW  CAREFULLY. IT OUTLINES HOW THE FEDERAL HEALTH INSURANCE PORTABILITY AND  ACCOUNTABILITY ACT OF 1996 (HIPAA) LEGISLATION AFFECTS HOW RECORDS IN MY  PRACTICE ARE KEPT AND MANAGED. 

Safeguards Governing Your Protected Health Information 

I understand that information about 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 use this record to provide you with quality care and to comply with legal requirements. “Protected Health Information” (PHI)  refers to information in your health record that could identify you. This includes information about your condition, the provision of health care to you, or payment for the health care. I make every effort to protect and prevent the dissemination of your PHI. 

I am required by law to: 

  • Maintain the privacy of your PHI. 

  • Give you this notice of my legal duties and privacy practices with respect to health information. • Follow the terms of the notice that is currently in effect. 

I reserve the right to change the privacy policies and practices obtained in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you with a revised notice through your secure client portal, by mail, or in person.  

This notice informs you about the ways in which I may use and disclose health information about you. I  also describe your rights to the health information I keep about you as well as certain obligations I have regarding the use and disclosure of your health information.  

Uses and Disclosures for Treatment, Payment, and Health Care Operations 

In accordance with the HIPAA act and its Privacy Rule (Rule), your PHI may be used and disclosed for the purposes of treatment, to obtain payment for services you receive, and for normal health care operations. To help clarify these terms, here are some definitions: For most other uses and/or disclosures of your PHI,  you will be asked to grant your permission via a signed Authorization. However, the Rule allows for certain specified uses and/or disclosures of your PHI. These consist of the following: 

  • “Treatment, Payment, and Health care operations” 

    • Treatment is when I provide, coordinate, or manage your health care and services related to your health care. Examples of treatment would be when I consult with another health care provider, such as your physician or another psychologist, or in the case of a medical emergency. 

    • Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.  

    • Health Care Operations are activities that relate to the performance and operation of my practice. Examples of Health Care Operations are quality assessment and improvement activities, audits, administrative services, case management, and care coordination.  

  • “Use” applies only to activities within my practice such as sharing, employing, applying, utilizing,  examining, and analyzing information that identifies you. 

  • “Disclosure” applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties. 

  • “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.  

Other Uses and Disclosures Requiring Authorization 

Generally, the use and/or disclosure of your PHI for any purpose that falls outside of the definitions of treatment, payment, and Health Care Operations identified above will require your signed Authorization. “Psychotherapy Notes” (as defined in 45 CFR § 164.501) are clinical notes that are not part of your PHI  and require your signed Authorization for release. If you grant your permission for use and/or disclosure of your PHI or Psychotherapy Notes, you retain the right to revoke your Authorization at any time, provided that each revocation is in writing. You may not revoke an authorization to the extent that a) a disclosure might already have been made, or 2) authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy. 

As a psychologist, I will not use or disclose your PHI for marketing purposes, nor will I sell your PHI in the regular course of my business.  

Uses and Disclosures Not Requiring Authorization 

The Rule provides that your PHI may be used and/or disclosed without your Authorization in the following circumstances: 

  • When disclosure is requested by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law. I may use and/or disclose your PHI in cases of suspected abuse, neglect, or intimate partner violence, including reporting the information to social service agencies. 

  • To avert a serious threat to health or safety. I may use and/or disclose your PHI in order to avert a  serious threat to health or safety. For example, if I believed you were at imminent risk of hurting yourself, or harming a person or propriety, I may disclose your PHI to prevent such an act from occurring.  

  • For health oversight activities, including audits and investigations, such as a request for review from the Centers for Medicare and Medicaid Services. 

  • For judicial and administrative proceedings, including responding to a court or administrative order, a warrant, subpoena, discovery request, or other lawful process. 

  • 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, such as studying and comparing treatment responses of mental health patients who received different forms of therapy for the same condition. 

  • For specialized government functions, such as protecting the President of the United States,  ensuring the proper execution of military missions, 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, in order to comply with workers’ compensation laws. • For health related benefits or services, such as informing you about treatment alternatives or other healthcare services or benefits. 

Your Rights Regarding Your Protected Health Information (PHI) 

The HIPAA Privacy Rule grants you each of the following individual rights: 

  • You have the right to request restrictions on certain uses and disclosures of your PHI. While I will consider your request, I am not legally bound to agree. If I agree to your request, I will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that I am legally required or permitted to make. 

  • In general, you have the right to view or obtain copies of your PHI for as long as the PHI is maintained in the record. You must request it in writing. Under certain circumstances, such as if the information may be considered harmful, I may deny your request. If your request is denied, you will be given in writing the reasons for the denial. You have the right to have the denial reviewed.  If you request copies of your PHI, you will be charged not more than $.25 per page. I may see fit to provide you with a summary or explanation of the PHI, but only if you agree in advance to it, as well as to the cost. 

  • It is your right to request and receive confidential communications of PHI by alternative means and at alternative locations. I am obliged to agree to your request providing that I can give you the PHI  in the format you requested without undue inconvenience. 

  • You are entitled to an accounting of disclosures of your PHI that I have made. The list will not include uses or disclosures to which you have already consented (e.g., those for treatment, payment,  or health care operations). The list will include the date of the disclosure, to whom PHI was disclosed (including address if known), a description of the information disclosed, and the reason for the disclosure. This will be provided to you at no cost, unless you make more than one request in the same year, in which case you will be charged a reasonable sum based on a set fee for each additional request. 

  • If you believe that there is some error in your PHI or that important information has been omitted,  it is your right to request that I correct the existing information or add the missing information.  Your request and the reason for your request must be made in writing. You will receive a response within 60 days of my receipt of your request. Your request may be denied if it is determined that:  the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d)  written by someone other than me. The denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and my denial be attached to any future disclosures of your PHI. If your request is approved, I will make the change(s) to your  PHI. Additionally, I will tell you that the changes have been made and will advise all other who need to know about the change(s) to your PHI. 

  • You have the right to receive a paper copy of this notice upon request, even if you have received the notice electronically. 

 

Complaints about these Privacy Practices 

If you have questions or concerns about this notice or object to a decision made about access to your PHI,  you may contact my office at (424) 432-0058. If believe that your individual privacy rights have been violated, you may submit a written complaint to Santa Monica Therapy at 3301 Ocean Park Blvd., Ste. 210,  Santa Monica, CA 90405. Your written complaint must name the person or entity that is the subject of your complaint and describe the acts and/or omissions you believe to be in violation of the Rule or the provisions outlined in our Notice of Privacy Practices. If you prefer, you may file your written complaint with the  Secretary of the U.S. Department of Health and Human Services: Office of Civil Rights (Room 515F), U.S. 

Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C., 20201. 

Any complaint you file must be received by my office or filed with the Secretary within 180 days of when you knew, or should have known, the act or omission occurred. I will take no retaliatory action against you if you make such complaints.