Notice of This Practice’s Privacy Policies
THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. YOU MAY HAVE ADDITIONAL RIGHTS UNDER STATE AND LOCAL LAW. PLEASE SEEK LEGAL COUNSEL FROM AN ATTORNEY LICENSED IN YOUR STATE IF YOU HAVE QUESTIONS REGARDING YOUR RIGHTS TO HEALTH CARE INFORMATION.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on January 1, 2018.
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
Under the Health Insurance Portability and Accountability Act of 1996 (hereafter, “HIPAA”), you have certain rights regarding the use and disclosure of your protected health information (hereafter, “PHI”).
I. CHARLENE’S PLEDGE REGARDING HEALTH INFORMATION:
Charlene C. Chow, LMHC, MPH (hereafter, “Charlene” or “she”) understands that health information about you and your health care is personal. Charlene is committed to protecting health information about you. She creates a record of the care and services you receive from her. She needs 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. This notice will tell you about the ways in which Charlene may use and disclose health information about you. She also describes your rights to the health information kept for you, and describes certain obligations she has regarding the use and disclosure of your health information.
Charlene is required by law to:
Make sure that PHI that identifies you is kept private.
Give you this notice of our legal duties and privacy practices with respect to health information.
Follow the terms of the notice that are currently in effect.
Charlene can change the terms of this Notice, and such changes will apply to all the information she has about you. The new Notice will be available upon request, in her electronic medical record system, and on her website.
II. HOW CHARLENE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that Charlene uses and discloses health information. For each category of uses or disclosures, she will explain what she means and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways she is permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have a direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. She may also disclose your PHI for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, she would be permitted to use and disclose your PHI, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your health condition. Charlene may also use your PHI for operations purposes, including sending you appointment reminders, billing invoices, and other documentation.
Disclosures for treatment purposes are not limited to the minimum necessary standard, because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, Charlene may disclose health information in response to a court or administrative order. She may also disclose health information about you or your minor child(ren) in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have already 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. Charlene does 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 her use in treating you.
For her use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
For her use in defending herself in legal proceedings instituted by you.
For use by the Secretary of the Department of Health and Human Services (HHS) to investigate her compliance with HIPAA.
Required by law and the use or disclosure is 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 who is performing duties authorized by law.
Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. Charlene will not use or disclose your PHI for marketing purposes without your prior written consent. Charlene will never request a review from you. However, if you offer to provide one voluntarily for the purpose of allowing Charlene to share the review publicly online or elsewhere to advertise her services or practice, she will provide you with a release form and HIPAA authorization. The HIPAA authorization is required in the instance that your review contains PHI (i.e., your name, the date of the service you received, the kind of treatment you are seeking or other personal health details). Because you may not realize which information you provide is considered “PHI,” Charlene will send you a HIPAA authorization and request your signature regardless of the content of your review. Once you complete the HIPAA authorization, she will have the legal right to use your review for advertising and marketing purposes, even if it contains PHI. You may withdraw this consent at any time by submitting a written request to her via the email address she keeps on file or via certified mail to her practice address. Once she has received your written withdrawal of consent, she will remove your review from her website and from any other places where it may be posted. She cannot guarantee that others who may have copied your review from her website or from other locations will also remove the review. This is a risk that she wants you to be aware of, should you give her permission to post your review.
Sale of PHI. As a clinician, she will not sell your PHI in the regular course of our business.
IV. USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, Charlene can use and disclose your PHI without your Authorization for the following reasons. She has to meet certain legal conditions before she can share your information for these purposes:
Appointment reminders and health-related benefits or services. She may use and disclose your PHI to contact you to remind you that you have an appointment with her. She may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that she offers.
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 or subpoena, although her preference is to obtain Authorization from you before doing so if allowed by the court or administrative officials.
For law enforcement purposes, including reporting crimes occurring on her 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 patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including: ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’ compensation purposes. Although her preference is to obtain Authorization from you first, she may be required to provide your PHI in order to comply with workers’ compensation laws.
For organ and tissue donation requests.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others: You have the right and choice to tell Charlene that she may provide your PHI to a family member, friend, or other person whom you indicate is involved in your care or the payment for your health care, or to share your information in a disaster relief situation. The opportunity to consent may be obtained retroactively in emergency situations to mitigate a serious and immediate threat to health or safety or if you are unconscious.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask Charlene not to use or disclose certain PHI for treatment, payment, or health care operations purposes. She is not required to agree to your request, and may say “no” if she believes it may negatively 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 the disclosure of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
The Right to Choose How We Send PHI to You. You have the right to ask Charlene to contact you in a specific way (for example, home phone or cell phone or email) or to send mail to a different address. Charlene will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than in limited circumstances, you have the right to get an electronic or paper copy of your medical record and other information that Charlene has about you. Please refer to Charlene’s Informed Consent documents or ask her how to go about doing this. She will provide you with a copy of your record, or if you agree, a summary of it, within 30 days of receiving your written request. She may charge a reasonable cost-based fee for doing so.
The Right to Get a List of the Disclosures Made. You have the right to request a list of instances in which Charlene has disclosed your PHI for purposes other than treatment, payment, or health care operations, and other disclosures (such as any you ask her to make). Please refer to Charlene’s Informed Consent documents or ask her how to go about doing this. She will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list she will give you will include disclosures made in the last six years unless you request a shorter time. She will provide the list to you at no charge, but if you make more than one request in the same year, she will charge you 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 from your PHI, you have the right to request that Charlene corrects the existing information or add the missing information. She may deny your request but 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. And, even if you have agreed to receive this Notice via email, you also have the right to request a paper copy of it.
The Right to Choose Someone to Act For You. If you have given someone medical power of attorney or if someone is your legal guardian, that person can make choices about your health information.
The Right to Revoke an Authorization.
The Right to Opt out of Communications and Fundraising from our Organization.
The Right to File a Complaint. You can file a complaint if you feel we have violated your rights by contacting Charlene by email, or by filing a complaint with HHS by calling (877) 696-6775 or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints. Charlene will not retaliate against you for filing a complaint.
VII. CHANGES TO THIS NOTICE
Charlene can change the terms of this Notice, and such changes will apply to all the information she may have about you. New Notices will be available upon request and on her website.