Introduction

This document is intended to describe how information about you may be used, shared, or disclosed by this office and how you may access the information.  This document must be provided to you in accordance with Health Insurance Portability and Accountability Act of 1996 and later revisions (HIPAA).  Information about HIPAA may be found at http://www.hhs.gov/ocr/hipaa.  Please read the entire document carefully and be sure to ask your therapist any questions or discuss any concerns that you may have regarding its contents BEFORE signing this document.  Definitions to terms contained in this document are provided at the end of the document for reference purposes.

Statements

1. Legal duty.  This office has a legal duty to safeguard your protected health information (PHI).  This office is required and takes steps to protect the privacy of your PHI.  This document is legally required to contain information about how, when, and why this office will use and disclose your PHI.  With some exceptions, this office may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made.  This office is legally required to follow the privacy practices described herein.  This office reserves the right to change this Notice and post a new copy of it in the office or on website(s) used by this office.  You may request a copy of this Notice from this office, or you may view it on the website(s) at your convenience.
2. How PHI May Be Used Or Disclosed.  This office will use and disclose your PHI for many different reasons. Some uses and disclosures of PHI will require your prior written authorization, some uses do not.  Uses and disclosures relating to treatment, payment, or health care operations do not require your prior written consent. This office can use and disclose your PHI without your consent for the following reasons:
   • For Treatment.  This office may use your PHI within this office to provide you with mental health treatment, including discussing or sharing your PHI with trainees and interns.  PHI may also be shared with professionals involved in your treatment for the purpose of coordinating your care, such as a psychiatrist who is treating you.
   • To Obtain Payment for Treatment.  This office may use and disclose your PHI to bill and collect payment for the treatment and services provided by this office to you.  For example, your information may be sent to a collection agency should this office not receive payment for services rendered.  PHI may also be shared with business associates, such as billing companies, claims processing, and others that process claims for services provided by this office.
   • For Health Care Operations.  This office may use and disclose your PHI as a course of business.  For example, this office may use your PHI to evaluate the quality of health care services you received or to evaluate the performance of the health care professionals who provided such services to you. This office may also provide your PHI to business associates such as accountants, attorneys, consultants, or others to further health care operations provided by this office.
   • Patient Incapacitation or Emergency. This office may also disclose your PHI to others without your consent if you are incapacitated or if an emergency exists. For example, your consent isn’t required if you need emergency treatment, as long as this office attempts to try to get your consent after treatment is rendered, or if this office tries to get your consent but you are unable to communicate with the office (for example, if you are unconscious or in severe pain) and this office thinks that you would consent to such treatment if you were able to do so.
3. Certain Other Uses and Disclosures Also Do Not Require Your Consent or Authorization. This office can use and disclose your PHI without your consent or authorization for the following reasons:
   • When federal, state, or local laws require disclosure. For example, this office may have to make a disclosure to applicable governmental officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect.
   • When judicial or administrative proceedings require disclosure. For example, if you are involved in a lawsuit or a claim for workers’ compensation benefits, this office may have to use or disclose your PHI in response to a court or administrative order. This office may also have to use or disclose your PHI in response to a subpoena.
   • When law enforcement requires disclosure. For example, this office may have to use or disclose your PHI in response to a search warrant.
   • When public health activities require disclosure. For example, this office may have to use or disclose your PHI to report to a government official an adverse reaction that you have to a medication.
   • When health oversight activities require disclosure. For example, this office may have to provide information to assist the government in conducting an investigation or inspection of a health care provider or organization.
   • To avert a serious threat to health or safety. For example, this office may have to use or disclose your PHI to avert a serious threat to the health or safety of others. However, any such disclosures will only be made to someone able to prevent the threatened harm from occurring.
   • For specialized government functions. If you are in the military, this office may have to use or disclose your PHI for national security purposes, including protecting the President of the United States or conducting intelligence operations.
   • To remind you about appointments and to inform you of health-related benefits or services. For example, this office may have to use or disclose your PHI to remind you about your appointments, or to give you information about treatment alternatives, other health care services, or other health care benefits that this office offers that may be of interest to you.
4. Certain Uses and Disclosures Require You to Have the Opportunity to Object.
   • Disclosures to Family, Friends, or Others. This office 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.
   • Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in sections 2, 3 and 4 above, this office will need your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that this office hasn’t taken any action in reliance on such authorization) of your PHI by this office.
5. What Rights You Have Regarding Your PHI.  You have the following rights with respect to your PHI:
   • The Right to Request Restrictions on My Uses and Disclosures. You have the right to request restrictions or limitations on my uses or disclosures of your PHI to carry out my treatment, payment, or health care operations. You also have the right to request that this office restrict or limit disclosures of your PHI to family members or friends or others involved in your care or who are financially responsible for your care. Please submit such requests to this office in writing. This office will consider your requests, but this office is not legally required to accept them. If this office does accept your requests, this office will put them in writing and this office will abide by them, except in emergency situations. However, be advised, that you may not limit the uses and disclosures that this office is legally required to make.
   • The Right to Choose How I Send PHI to You.  You have the right to request that this office send confidential information to you to at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail). This office must agree to your request so long as it is reasonable and you specify how or where you wish to be contacted, and, when appropriate, you provide me with information as to how payment for such alternate communications will be handled. This office may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.
   • The Right to Inspect and Receive a Copy of Your PHI.  In most cases, you have the right to inspect and receive a copy of the PHI that this office has on you, but you must make the request to inspect and receive a copy of such information in writing. If this office doesn’t have your PHI but this office knows who does, this office will inform you how to get it.  This office will respond to your request within 30 days of receiving your written request. In certain situations, this office may deny your request. If this office does, then this office will tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed.  If you request copies of your PHI, this office will charge you not more than $0.25 for each page. Instead of providing the PHI you requested, this office may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance.
   • The Right to Receive a List of the Disclosures This Office Has Made. You have the right to receive a list of instances, i.e., an Accounting of Disclosures, in which this office has disclosed your PHI. The list will not include disclosures made for my treatment, payment, or health care operations; disclosures made to you; disclosures you authorized; disclosures incident to a use or disclosure permitted or required by the federal privacy rule; disclosures made for national security or intelligence; disclosures made to correctional institutions or law enforcement personnel; or, disclosures made before April 14, 2003.  This office will respond to your request for an Accounting of Disclosures within 60 days of receiving such request. The list will include disclosures made in the last six years unless you request a shorter time. The list will include the date the disclosure was made, to whom the PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. This office will provide the list to you at no charge, but if you make more than one request in the same year, this office may charge you a reasonable, cost-based fee for each additional request.
   • The Right to Amend 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 this office correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. This office will respond within 60 days of receiving your request to correct or update your PHI. This office may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by this office, (iii) not allowed to be disclosed, or (iv) not part of my records. Written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don’t file one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If this office approves your request, this office will make the change to your PHI, tell you that this office has done it, and tell others that need to know about the change to your PHI.
   • The Right to Receive a Paper Copy of this Notice.  You have the right to receive a paper copy of this notice even if you have agreed to receive it via e-mail.
6. How To Complain About Our Privacy Practices.  If you think that this office may have violated your privacy rights, or you disagree with a decision this office has made about access to your PHI, you may file a complaint with the person listed in the section below. You also may send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. This office will take no retaliatory action against you if you file a complaint about my privacy practices.
7. Person To Contact For Information About This Notice Or To Complain About My Privacy Practices.  If you have any questions about this notice or any complaints about this office’s privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services please contact us at the address or phone number in the header or the Office of Civil Rights, US Department of Health and Human Services, Region IX – San Francisco, 90 7th Street, Suite 4-100, San Francisco, CA 94103.  Phone (415) 437-8310.  TDD (415) 437-8311.
8. Effective Date Of This Notice.  This notice went into effect on June 14, 2017.