Notice of Privacy Practices
Notice of Privacy Practices
This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Uses and Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
“PHI” refers to information in your health record that could identify you
“Treatment, Payment, and Health Care Operations”:
Treatment is when your therapist provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be when he/she consults with another health care provider, such as your family physician or another psychotherapist.
Payment is when your therapist obtains reimbursement for your healthcare. Examples of payment are when he/she discloses your 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 the practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
“Use” applies only to activities within your therapist’s office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of your therapist’s office such as releasing, transferring, or providing access to information about you to other parties.
Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: Whenever I, in my professional capacity, have knowledge of or reasonable cause to suspect that a child has been the victim of abuse or neglect, I must immediately report such knowledge or suspicion to a police or sheriff’s department, county probation department, or county welfare department (child protective services). If I have knowledge of or reasonable cause to suspect a child is suffering serious emotional damage or is at substantial risk of suffering serious emotional damage, I may report such to the above agencies.
Elder and Dependent Abuse: If I, in my professional capacity, have observed, have knowledge of, or have been told by an elder or dependent adult that the elder or dependent adult has experienced behavior (including an act of omission) constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, I must immediately report such knowledge or suspicion to the local law enforcement agency, local ombudsman, and/or corresponding licensing agency.
I am not required to file a report when I have been told by an elder or dependent adult that he/she has experienced an act that constitutes reportable abuse, but all of the following conditions apply:
I do not have any independent corroborating evidence that the abuse occurred,
The adult has received a diagnosis of dementia or a mental illness or is the subject of a court-ordered conservatorship because of dementia or a mental illness, and,
Based on my clinical judgment, I reasonably believe that the abuse has not occurred.
Health Oversight: If a complaint is filed against me with the California Board of Psychology, the Board has the authority to subpoena confidential mental health information from me relevant to that complaint.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis or treatment and the records thereof, such information is privileged under state law. I will not release information without the written authorization of you or your legal representative, or a subpoena of which you have been properly notified and you have failed to inform me that you are opposing the subpoena, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
Serious Threat to Health or Safety: If you communicate to me (or your family member informs me that you have communicated) a serious threat of physical violence against an identifiable victim, I must make reasonable efforts to communicate that information to the potential victim and the police. If I have reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, I may release relevant information as necessary to prevent the threatened danger.
Worker’s Compensation: If you file a worker's compensation claim, I must, upon request of your employer, the insurance carrier, an authorized qualified rehabilitation provider, or the attorney for the employer or insurance carrier, furnish your relevant records to those persons.
There may be additional disclosures of PHI that I am required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common.
Patient’s Rights and Therapist’s Duties
Patient’s Rights:
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.)
Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.
Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.
Right to a Paper Copy: You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
Therapist’s Duties:
I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
I reserve the right to change the privacy policies and practices described 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 in person or by mail.