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 read it carefully. Your medical and mental health treatment information and records are personal and private.
I am committed to protecting your health information. The information created and maintained is known as Protected Health Information, or PHI. I am required by Federal and State laws to protect the privacy of your medical and mental health information and obtain a signed authorization by you for certain disclosures. I am required by law to provide you with this notice of our legal duties and privacy practices with respect to your medical and mental health information. This notice is intended to let you know of my legal duties, your rights, and my privacy practices with respect to such information. I am required to abide by the terms of the notice currently in effect. I reserve the right to change the terms of this notice and/or my privacy practices and to make the changes effective for all protected health information that I maintain, even if it was created or received prior to the effective date of the notice revision. If I make a revision to this notice, I will make the notice available at my office upon request on or after the effective date of the revision and I will post the revised notice in a clear and prominent location.
HOW I MAY USE AND DISCLOSE YOU PROTECTED HEALTH INFORMATION
I will use and disclose your PHI for many different reasons. For some of these uses or disclosures, I will need your prior authorization; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category.
1. Treatment I may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. I may also disclose your health information to other providers who may be treating you or involved in your care. For example, if you're being treated by a psychiatrist, I can disclose your PHI to your psychiatrist in order to coordinate your care.
2. Payment I may use or disclose your protected health information to obtain payment for the health care services provided to you. For example, I may include information with a bill to your insurance company or those paying for your treatment, that identifies you, your diagnosis, and services provided in order to receive payment. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.
3. Health Care Operations I may use and disclose your protected health information to support business activities such as medical billing, insurance verification, and submitting medical claims to your insurance company on your behalf. I may disclose your health information with other staff or business associates, who perform billing, consulting, auditing, investigatory, and other services.
4. Medical Emergencies 2. Notice of Privacy Practices I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. I will try to provide a copy of this notice as soon as reasonably practical after the resolution of the emergency.
5. Deceased Patients I may disclose PHI regarding decreased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a decease person’s estate. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.
6. Health Oversight If required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third part payors based on your prior consent) and peer review organizations performing unitization and quality control.
7. Law Enforcement I may disclose PHI to a law enforcement officials as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency or in connection with a crime on the premises.
8. Child Abuse: Whenever I have knowledge of or observe a child I reasonably suspect has been the victim of child abuse or neglect, it must be reported immediately. Also, if there is knowledge of or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional well-being is endangered in any other way it must be reported to local law enforcement agency or child protective services.
9. Elder or Dependent Adult Abuse: If in professional capacity I observe or gain knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if told by an elder dependent adult that he or she has experienced these or if there is reason to suspect such, I must report the known or suspected abuse immediately to the local ombudsman or local law enforcement agency.
10. Harm to Self or Others If you are in such mental or emotional condition as to be dangerous to yourself or to the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger, I will notify the police, crisis assessment team, emergency contact, of whomever else I feel is essential in preventing harm.
11. Harm to an Identifiable Person If you tell me of a serious threat (imminent) of physical violence to be committed by you against a reasonably identifiable victim or victims, I will notify the police and attempt to notify the victim of your intent to harm.
12. Lawsuits and Legal Actions I may disclose your protected health information in response to a court order, subpoena, or other lawful process, as allowed by law, for legal proceedings.
13. To Stop a Serious Threat to Public Health or Safety I may use or disclose your protected health information if it is necessary to lessen the imminent threat of a serious threat to health or safety.
14. Workers’ Compensation I will use and disclose your protected health information for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.
15. Family and Friends Involved in or Paying for Your Care I may disclose your protected health information to a friend, family member, or any other person you identify as being involved with your medical care or payment for care. For example, you may bring a friend or family member to your appointment and have that person in the exam room while talking with a health care provider. You may inform me verbally or in writing if you object to disclosures to your family and friends.
PLEASE NOTE: The above is not an exhaustive list, but informs you of most circumstances when disclosures without your written authorization may be made. Other uses and disclosures will generally (but not always) be made only with your written authorization, even though federal privacy regulations or state law may allow additional uses or disclosures without your written authorization. Uses or disclosures made with your written authorization will be limited in scope to the information specified in the authorization form, which must identify the information “in a specific and meaningful fashion.” If California law protects your confidentiality or privacy more than the federal “Privacy Rule” does, or if California law gives you greater rights than the federal rule does with respect to access to your records, I will abide by California law.
COMMUNICATION
Appointment Reminders I may use the contact information that you provided to remind you of your upcoming appointments. If you prefer I did not use appointment reminders, please let me know as soon as possible and I will discontinue them. Email exchanges with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters because email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me so we can discuss it on the phone or wait so we can discuss it during your therapy session. I will to send unencrypted emails if you are advised of the risk and still request that form of transmission.
Billing
If you pay for your sessions out of pocket or via co-pay, you will be expected to pay for each session. If your credit card is declined you will be asked to pay in cash for your next session. If your credit card is declined twice, you will be asked to prepay for your session 24 hours in advance. If your credit card is declined your session will be cancelled. At that point please consider if the timing is right for you to continue therapy.
Letter Writing
I do not write letters for emotional support animals. I am not an expert in animal behavior and I do not feel comfortable writing a letter giving permission for an animal that I've never met or seen interact in the world in which I may be liable for. I also do not write letters for FMLA, medical certification, school or work ADA accommodation, or prolonged absences from work or school. However, I can write a letter excusing you from work or school to attend your therapy session. Thank you for understanding.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION REQUIRING YOUR PERMISSION
I will obtain your written permission through an authorization for other uses and disclosures of your protected health information not covered by this Notice. You may revoke the authorization in writing at any time and we will stop disclosing protected health information about you for the reasons stated in your written authorization. Any disclosures made prior to the revocation are not affected by the revocation. I am also required to retain our records of the care you receive for seven years.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU
1. Right to Inspect and Copy You have the right to inspect and copy the protected health information in our designated record set, as long as we maintain that information. You have the right to access your records in any format that we maintain them in and you may direct them to be sent to a third party. A request must be submitted in writing and a fee may be charged for the costs of copying, mailing, and for any other supplies used in fulfilling your request. I may deny your request to inspect and copy your records. If this occurs, I will send you a written statement as to why and I will explain your right, if any, to have the denial reviewed.
2. Right to Request an Amendment You have the right to request that we amend your protected health information if you feel that it is incomplete or inaccurate. The request must be in writing and provide reasons that support your request including what information is incomplete or inaccurate. I may deny your request if it is not in writing or does not include a reason to support the request. I may also deny your request if: • The information is correct and accurate. • The information was not created by me or the person who created it is no longer available to make the amendment. • The information is not part of the records you are permitted to inspect and copy. If I deny your request for amendment, you have the right to file a written addendum.
3. Right to Request Restrictions You have the right to request a restriction or limitation on how I use or disclose your protected health information for treatment, payment, or health care operations. For example, you could ask me to limit the information shared with someone who is involved in your care or the payment for your care.
4. Right to Request Confidential Communications You have the right to request how I communicate with you to preserve your privacy. For example, you may request that I call you only at your work number, or send mail to a special address. Your request must be made in writing and must specify how or where we are to contact you or you may use the patient portal to specify your request. I will accommodate all reasonable requests.
5. Right to Revoke an Authorization You have the right to take back or revoke your written authorization to use and disclose your protected health information at any time. You must let us know in writing. If you take back your written authorization, we will stop sharing your protected health information once we receive the request. However, we cannot take back any information already used or shared while the authorization was valid. I am required by law to keep a record of the treatment you receive, whether or not you give us written permission to use or share it. You do not have the right to have information removed from your record.
6. Breach Notification In the event of a breach of your unsecured protected health information, you will be notified of the circumstances of the breach.
7. Right to Alternative Means You have the right to receive confidential communications of protected health information from me by alternative means or at alternative locations.
8. Accounting From Me You have the right to receive an accounting from me of the disclosures of protected health information made by me in the seven years prior to the date on which the accounting is requested. As with other rights, this right is not absolute. In other words, I am permitted to deny the request for specified reasons. For instance, I do not have to account for disclosures made in order to carry out my own treatment, payment or health care operations. I also do not have to account for disclosures of protected health information that are made with your written authorization, since you have a right to receive a copy of any such authorization you might sign.
9. Paper Copy You have the right to obtain a paper copy of this notice from me upon request. If you think I may have violated your privacy rights, you may file a complaint with me, as the Privacy Officer for my practice, and my address and phone number are: 31915 Rancho California Rd Suite 200-112, Temecula, CA 92591 951-973-2450 You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by: Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201. You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint. EFFECTIVE DATE OF THIS NOTICE This notice went into effect on July 1, 2019.