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NOTICE OF PRIVACY PRACTICES AND HIPAA COMPLIANCE
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. PLEDGE REGARDING HEALTH INFORMATION:
Our office understands that health information about you and your health care is personal. Our office is committed to protecting health information about you. Our office creates a record of the care and services you receive from your therapist. Our officeneeds 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 our office may use and disclose health information about you. This document also describes your rights to the health information our office keeps about you, and describes certain obligations our office has regarding the use and disclosure of your health information. Our office is required by law to:
● Make sure that protected health information (“PHI”) that identifies you is kept
private.
● Give you this notice of our offices legal duties and privacy practices with respect
to health information.
● Follow the terms of the notice that is currently in effect.
● Our office can change the terms of this Notice, and such changes will apply to
all information our office has about you. The new Notice will be available upon
request or our office will send a new copy of the change to you when changes
happen.
II. USE AND DISCLOSURE OF HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that our office uses and discloses health information. For each category of uses or disclosures our office will explain what it means and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways our office 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 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. Our office may also disclose your protected health information 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, our office would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition. If you are assigned to an associate therapist and the associate consults with their supervisor about your condition, our office would be permitted to use and disclose your personal health information. 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 1/17/24, 12:27 PM Preview consent document – SimplePractice
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care provider to another.
Lawsuits and Disputes:
If you are involved in a lawsuit, our office may disclose health information in response to a court or administrative order. Our office may also disclose health information about your minor child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have 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. Our office keeps “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:
a. For our use in treating you.
b. For our use in training or supervising mental health practitioners to help them
improve their skills in group, joint, family, or individual counseling or therapy.
c. For our use in defending ourselves in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate our
compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of
such law.
f. Required by law for certain health oversight activities pertaining to the
originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
● Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for
marketing purposes.
● Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of
our business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, Our office can use and disclose your PHI without your uuthorization for the following reasons:
● 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’s1/17/24, 12:27 PM Preview consent document – SimplePractice
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health or safety.
● For health oversight activities, including audits and investigations.
● For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
● 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, 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 my preference is to obtain an Authorization from you, We may provide your PHI in order to comply with workers’ compensation laws.
● Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with me. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
● Disclosures to family, friends, or others. Our 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.
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 our office not to use or disclose certain PHI for treatment, payment, or health care operations purposes. Our office is not required to agree to your1/17/24, 12:27 PM Preview consent document – SimplePractice
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request, and our office may say “no” if it would 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 disclosures 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 Our Office Sends PHI to You. You have the right to ask me to contact you in a specific way (for example: Phone calls, text messages, secure messages or email) and we will agree to all reasonable requests.
● The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic copy of your medical record and other information that our office has about you. Our office will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and our office may charge a reasonable, cost based fee for doing so based on an hourly rate.
● The Right to Get a List of the Disclosures Our Office Has Made. You have the right to request a list of instances in which our office has disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided our office with an Authorization. Our office will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list our office will give you will include disclosures made in the last six years unless you request a shorter time. Our office will provide the list to you at no charge, but if you make more than one request in the same year, our office 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 our office correct the existing information or add the missing information. Our office may say “no” to your request, but our office 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 this1/17/24, 12:27 PM Preview consent document – SimplePractice
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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.
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE AND HIPAA COMPLIANCE
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information.
By checking the box for this notice in our secure portal, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.
By signing this form in our secure portal you are authorizing FInd Your Balance, Center for Growth & Change Inc. and all its business name entities and employees to phone, text, secure message and or email you at your non HIPAA compliant email.
Examples of why we would call, text, secure message or email you are insurance verifications, appointment dates and times, reminders to complete documents, medical record requests, weekly sessions links and any other information related to our office.
Our office can’t guarantee the security of a voicemail , text message, secure message or email if it’s not HIPAA compliant. Please keep in mind that communications via email over the Internet are not secure.
Although it is unlikely, there is a possibility that information you include in a phone call , text or email can be intercepted and read by other parties besides the person to whom it is addressed.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect in January 2020 and has been updated as of June 2022.
Find Your Balance, Center for Growth & Change
15720 Ventura Blvd Suite 420, Encino CA 91436
(818) 927-0478 / office@findyourbalancecenter.com / findyourbalancecenter.com