As Required by the Privacy Regulations created as a result of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A CLIENT OF THIS OFFICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUAL IDENTIFIABLE HEALTH INFORMATION
PLEASE REVIEW THIS NOTICE CAREFULLY
A. MY COMMITMENT TO YOUR PRIVACY
My office is dedicated to maintaining the privacy of your Individually Identifiable Health Information (IIHI). In conducting my practice, this Office will create records regarding you and treatment and services I provide you. I am required by law to maintain the confidentiality of health information that identifies you. I also am required by law to provide you with this Notice of my legal duties and the privacy practices that I maintain in my office concerning your IIHI. Under federal and state law, I must apply and follow the terms of the Notice of Privacy Practices that I have in effect at the time.
I realize that these laws are complicated, but I must provide you with the following important information:
The "USE" of this information applies to the sharing, utilization, examination, or analysis of your IIHI with my office. Your IIHI is "DISCLOSED" when it is released or transferred out of this office to another party or entity. These practices will be explained to you in this Notice. My Office has the legal duty, with some exceptions, to disclose or use only the necessary IIHI to accomplish the task at hand.
- How I may use and disclose your IIHI
- Your privacy rights in your IIHI
- My obligations concerning the use and disclosure of your IIHI
The terms of this notice apply to all records containing your IIHI that are created or retained by this Office. I reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this Notice will be effective for all of your records that this Office has created or maintained in the past, and for any of your records that I may create or maintain in the future. My Office will post a copy of its current Notice of Privacy Practices in this Office in a visible location at all times, and you may request a copy of my most current Notice of Privacy Practices at any time by notifying the PRIVACY OFFICER at the address and telephone number located in Paragraph B of this Notice.
B. PRIVACY OFFICER
If you have questions or want further information about this Notice, please contact my PRIVACY OFFICER:
16161 Ventura Blvd., Suite 229
Encino, CA 91436
C. USE AND DISCLOSURE OF YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI)
My Office is permitted to use and disclose your IIHI for the purposes of providing Treatment, Payment for services rendered, and Healthcare Operations. Some of these require your authorization and others do not.
The following categories describe the different ways in which my Office may use and disclose your IIHI without your authorization.
D. YOUR RIGHTS REGARDING YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI)
- Treatment: My Office may use and disclose your IIHI to a physician, psychiatrist, or other mental health clinicians who provide treatment to you. The purpose of this disclosure is for coordination of your treatment.
- Payment: My Office may use and disclose your IIHI in order to bill and collect payment for the services you receive from me. For example, if you use your health insurance to pay a part of my fees, I will contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and I may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment.
My Office also may use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members, or your health insurer. Health insurance companies usually want only your diagnosis, my fee, and when we met, and sometimes a treatment plan or summary of treatment. It is usually against the law for insurance companies to release any data about your office visits without your written permission (given only by signing a Release Form). While I believe the insurance company will act ethically and legally, I cannot control who sees this information at the insurer's office.
If my Office uses a third party for billing services, I will make sure they comply with the safe management of your IIHI.
- Healthcare Operations: My Office may use and disclose your IIHI for the purpose of maintaining and running this Office. This includes quality assessment protocols, reviewing the competence of clinicians providing treatment, or conducting training, certification or licensing activities.
- Appointment Reminders and Other Communications: My Office may use and disclose your IIHI to contact you and provide you with future or missed appointment reminders, appointment changes, or other office communications. These may include voice mail messages, letters, or E-mails.
- Emergency Situations: My Office may use and disclose your IIHI information to emergency personnel in cases where a situation warrants such treatment. In these situations I would only reveal the least amount of information necessary to treat the emergency and not tell everything you have told me.
- Federal, State, Local, or Administrative Law: My Office may use or disclose your IIHI when mandated by law. This includes reporting - child and/or elder/dependent abuse - harm to yourself or others - when required by judicial or administrative actions - or when required by government agencies such as a county coroner or workers compensations laws.
- National Security: My Office may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. My Office may also disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
- Authorization: My Office may obtain your written authorization to use or disclose your IIHI for situations not listed above. You may give my Office your written authorization to use your IIHI or to disclose your IIHI to anyone for any purpose as defined by your written AUTHORIZATION TO RELEASE CLIENT INFORMATION. You may revoke your authorization at any time but must submit your request in writing.
- Family, Friends, or Others Involved in Your Healthcare: My Office may provide your IIHI to a family member, friend, or other individual designated by you as being involved in your healthcare or for the payment of your healthcare, unless you object.
- Inspection and Copies: You have the right to inspect and obtain a copy of your IIHI, with some limited exceptions. For example, if I believe that some of what I have written in your record would seriously upset you, I can leave it out but I will fully explain my reasons to you. My Office will attempt to comply with your requested format, unless we are able to do so.
You must submit your request in writing to the Privacy Officer [Rob Kaufman, 16161 Ventura Blvd., Suite 224, Encino, CA 91436. (818) 788-9567] and my Office will respond within 5 days of receiving your written request. You will be charged $_____ per page. You will be charged a fee for the costs of copying, mailing, labor and supplies associated with your request. I may choose to provide you with a summary or synopsis of your IIHI but only if you agree. My Office may deny your request to inspect and/or copy under certain limited circumstances. Should my Office deny your request, you will be provided a reason in writing and an explanation of your rights to initiate a review of the denial.
- Requesting Restrictions on Uses and Disclosures of Your IIHI: You have the right to request restrictions in my use or disclosure of your IIHI for treatment or payment of your healthcare. Additionally, you have the right to request that I restrict my disclosure of your IIHI to only certain individuals involved in your healthcare, such as family members or friends. You must submit your request in writing to the Privacy Officer [Rob Kaufman, 16161 Ventura Blvd., Suite 224, Encino, CA 91436. (818) 788-9567] and my Office will respond within 5 days of receiving your written request. Your request must describe in a clear and concise way:
- The information you wish restricted;
- Whether you are requesting to limit my Office's use, disclosure or both; and
- To whom you want the restrictions to apply.
Your request may not interfere with the legally defined uses and disclosures of your IIHI. I am not required to agree to your request; however, if I do agree, I am bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
- Receiving Health Information: You have the right to request that my Office communicate with you about your health information in a particular manner or at a certain location. For example, you may request that we contact you at home, rather than work, or by E-mail. My Office will accommodate reasonable requests. You do not need to give a reason for your request. In order to request a type of communication you must submit your request in writing to the Privacy Officer [Rob Kaufman, 16161 Ventura Blvd., Suite 224, Encino, CA 91436. (818) 788-9567] specifying the requested method of communication, and/or the location where you wish to be contacted.
- Accounting of Disclosures: You have the right to request and receive an "accounting of disclosures." An "accounting of disclosures" is a list of certain non-routine disclosures my Office has made of your IIHI for reasons other than Treatment, Payment, or Healthcare purposes. In order to obtain an accounting of disclosures, you must submit your request in writing to the Privacy Officer [Rob Kaufman, 16161 Ventura Blvd., Suite 224, Encino, CA 91436. (818) 788-9567]. All requests for an "accounting of disclosures" must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but my Office may charge you for additional lists within the same 12-month period. My Office will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
- The Right to Amend Your Health Information: You have the right to request an amendment or correction to your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as your health information is kept by or for my Office. To request an amendment, you must submit your request in writing to the Privacy Officer [Rob Kaufman, 16161 Ventura Blvd., Suite 224, Encino, CA 91436. (818) 788-9567] You written request must provide a reason that supports your request for an amendment. My Office must respond to your written request within (60) sixty days of receiving the request.
My Office will deny your request if you fail to submit your request and/or the reason supporting your request in writing. Also, my Office may deny your request if you ask us to amend information that, in our opinion, is : (a) accurate and complete; (b) not part of the IIHI kept by or for my Office; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by my Office, unless the individual or entity that created the information is not available to amend the information. My Office will send you a written statement stating the reason for a denial. You will be provided with the format to file a written disagreement with the denial. You also have the right to request that your original request to amend your health information be attached to all future disclosures of your IIHI.
If your request to amend your health information is granted, the appropriate changes will be made, you will be notified of the changes made and third parties need to know about the changes will be notified.
- Electronic or Paper Notification: You have the right to receive a paper copy of this Notice of Privacy Practices or receive it by E-mail.
- Right to Provide an Authorization for other Uses and Disclosures: My Office will obtain your written authorization for uses and disclosures that are not identified by this Notice or permitted by applicable law. Any authorization you provide to my office regarding the use and disclosure of your IIHI may be revoked at any time but the revocation must be in writing. After your revoke your authorization, my Office will not longer use or disclose your IIHI for the reasons described in the authorization.
- Complaint Procedures: If you believe that my Office has violated your privacy rights, you disagree with a decision made about access to your health information, you disagree with a response to your request to amend or restrict the use or disclosure of your health information, or disagree with my Offices's decision to contact you via a specific method or location, you may file a complaint with my Office and/or with the Department of Health and Human Services. To file a complaint with my Office, contact my Privacy Officer [Rob Kaufman, 16161 Ventura Blvd., Suite 224, Encino, CA 91436. (818) 788-9567]. To file a complaint with the Department of Health and Human Services, contact , [Secretary of the United States Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C., 20201]. My office will not retaliate against you in any way should you choose to file a complaint.
If you have any questions regarding this Notice or our health information privacy policies, please contact our Privacy Officer:
16161 Ventura Blvd., Suite 224
Encino, CA 91436
The EFFECTIVE DATE of this NOTICE OF PRIVACY PRACTICES is APRIL 14, 2003.