NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about patients in my private practice may be used and disclosed and how patients can get access to this information.
I request that patients in my private practice review this notice carefully.
The privacy of health information is important to my practice

What Is Medical Information?

The term “medical information” is synonymous with the terms “personal health information” and “protected health information” for purposes of this Notice. It essentially means any individually identifiable health information (either directly or indirectly identifiable), whether oral or recorded in any form or medium, that 1) is created or received by a health care provider (me), health plan, or others and 2) relates to the past, present, or future physical or mental health or condition of an individual (patient); the provision of health care (for instance, mental health) to an individual (patient); or the past, present, or future payment for the provision of health care to an individual (patient).

I am a mental health care provider. More specifically, I am a Licensed Marriage and Family Therapist, licensed by the State of California through the Board of Behavioral Sciences. I create and maintain treatment records that contain individually identifiable health information about my patients. It is common to refer to these records as medical records or mental health records, and this Notice, among other things, concerns the privacy and confidentiality of those records and the information contained therein.

Uses and Disclosures without Patient Authorization: For Treatment, Payment, or Health Care Operations
Treatment: Federal privacy rules (regulations) allow health care providers (me) who have a direct treatment relationship with the patient to use or disclose the patient'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. I may also disclose a patient's protected health information for the treatment activities of any health care provider. I can also do that without a patient's written authorization.

Here is an example of a use or disclosure for treatment purposes: If I decide to consult with another licensed health care provider about my patient's condition, regulations would permit me to use and disclose personal health information, which is otherwise confidential, to assist me in the diagnosis or treatment of a mental health condition.

things, the coordination and management of health care among health care providers or by a health care provider with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another.

Payment: Here is an example of a use or disclosure for payment purposes: If a patient's health plan requests a copy of my patient's health records, or a portion thereof, to determine whether or not payment is warranted under the terms of my patient's policy or contract, regulations permit me to use and disclose my patient's personal health information.

Healthcare Operations: Here is an example of a use or disclosure for health care operations purposes: If a patient's health plan decides to audit my practice to review my competence and my performance, or to detect possible fraud or abuse, my patient's mental health records may be used or disclosed for those purposes.

PLEASE NOTE: I, or someone in my practice acting with my authority, may contact my patients to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to my patients. Such contact does not require my patients' prior written authorization.

Other Uses and Disclosures without Patient Authorization
Regulations may require or permit me to disclose my patient's personal health information (for example, a patient's mental health records) without my patient's written authorization. The following list gives examples of circumstances under which such disclosures may or will be made:

1. If disclosure is compelled by a court pursuant to an order of that court
2. If disclosure is compelled by a board, commission, or administrative agency for purposes of adjudication pursuant to its lawful authority
3. If disclosure is compelled by a party to a proceeding before a court or administrative agency pursuant to a subpoena, subpoena duces tecum (for example, a subpoena for mental health records), notice to appear, or any provision authorizing discovery in a proceeding before a court or administrative agency
4. If disclosure is compelled by a board, commission, or administrative agency pursuant to an investigative subpoena issued pursuant to its lawful authority
5. If disclosure is compelled by an arbitrator or arbitration panel, when arbitration is lawfully requested by either party, pursuant to a subpoena duces tecum (for instance, a subpoena for mental health records), or any other provision authorizing discovery in a proceeding before an arbitrator or arbitration panel
6. If disclosure is compelled by a search warrant lawfully issued to a governmental law enforcement agency
7. If disclosure is compelled by the patient or the patient’s representative pursuant to Chapter 1 (commencing with Section 123100) of Part 1 of Division 106 of the California Health and Safety Code or by corresponding federal statutes or regulations (for instance, the federal Privacy Rule, which requires this Notice)

1. If disclosure is compelled by the California Elder/Dependent Adult Abuse Reporting Law (for instance, if I have a reasonable suspicion of elder abuse or dependent adult abuse)
2. If disclosure is compelled or permitted by the fact that my patient is in such mental or emotional condition as to be dangerous to him/herself or to the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger
3. If disclosure is compelled or permitted by the fact that my patient tells me of a serious threat (imminent) of physical violence to be committed by him/her against a reasonably identifiable victim or victims
4. If disclosure is compelled or permitted, in the event of my patient's death, by the coroner to determine the cause of that patient's death
5. As indicated above, regulations permit me to contact a patient without a patient's prior authorization to provide appointment reminders, information about alternatives or other health-related benefits, and services that may be of interest to a patient. My patients let me know where and by what means (for example, telephone, letter, e-mail, fax) to contact them.
6. If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law, including but not limited to audits, criminal or civil investigations, or licensure or disciplinary actions. The California Board of Behavioral Sciences, who license marriage and family therapists, is an example of a health oversight agency.
7. If disclosure is compelled by the U. S. Secretary of Health and Human Services to investigate or determine my compliance with privacy requirements under the federal regulations (the Privacy Rule)
8. If disclosure is otherwise specifically required by law.

PLEASE NOTE: The above list is not an exhaustive one, but it informs my patients of most of the circumstances under which disclosures without a patient's written authorization may be made. Other uses and disclosures generally (but not always) occur only with patient’s written authorization, even though federal privacy regulations or state law may allow additional uses or disclosures without a patient's written authorization. Regulations limit the scope of uses or disclosures made with a patient's written authorization to the information specified in the authorization form, which must identify the information in a specific and meaningful fashion.

A patient may revoke his or her written authorization at any time, provided that the revocation is in writing and except to the extent that I have taken action in reliance on that written authorization. A patient's right to revoke an authorization is also limited if the authorization was obtained as a condition of obtaining insurance coverage for that patient. If California law protects a patient's confidentiality or privacy more than the federal Privacy Rule does, or if California law gives a patient greater rights than the federal rule does with respect to access to a patient’s records, I will abide by California law.

1. Patients have the right to request restrictions on certain uses and disclosures of protected health information about themselves, such as those necessary to carry out treatment, payment, or health care operations. I am not required to agree to such requested restrictions. If I do agree, I will maintain a written record of the agreed-upon restriction.
2. Patients have the right to receive confidential communications of protected health information from me by alternative means or at alternative locations.
3. Patients have the right to inspect and copy protected health information about themselves by making a specific request to do so in writing. This right to inspect and copy information is not absolute. In other words, I am permitted to deny access for specified reasons. For instance, my patients do not have this right of access with respect to my psychotherapy notes that are a mental health professional’s documentation or analysis of the contents of conversation during a private, joint, group, or family counseling session and that are separated from the rest of the individual’s medical (includes mental health) record. The term excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of furnished treatment, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
4. Patients have the right to amend protected health information in my records by making a request to do so in a writing that provides a reason to support the requested amendment. This right to amend information is not absolute. In other words, I am permitted to deny the requested amendment for specified reasons. Patients also have the right, subject to limitations, to provide me with a written addendum with respect to any item or statement in my records that the patient believes to be incorrect or incomplete and to have the addendum become a part of that patient's record.
5. Patients have the right to receive an accounting from me of the disclosures of protected health information made by me in the six years prior to the date on which they request the accounting. 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 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 a patient's written authorization, as a patient has a right to receive a copy of any such authorization he or she might sign.
6. Patients have the right to obtain a paper copy of this Notice from me upon request.

information about any of the above rights or their limitations, I invite him or her to let me know.  I am willing to discuss any of these matters with my patients. As mentioned elsewhere in this document, I am the Privacy Officer of this practice.


My Duties
I am required by law to maintain the privacy and confidentiality of my patients' personal health information. The purpose of this Notice is to let my patients know of my legal duties, their 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.

As the Privacy Officer of this practice, I have a duty to develop, implement, and adopt clear privacy policies and procedures for my practice, and I have done so. I am the individual who is responsible for assuring that these privacy policies and procedures are followed not only by me but also by any employees that work for me or that may work for me in the future. I have trained or will train any employees that may work for me so that they understand my privacy policies and procedures. In general, patient records and information about patients are treated as confidential in my practice and are released to no one without the written authorization of the patient, except as indicated in this Notice or except as may be otherwise permitted by law. Patient records are kept secured so that they are not readily available to those who do not need them.

Because I am the Contact Person of this practice, a patient may complain to me and to the Secretary of the U.S. Department of Health and Human Services if a patient believes his or her privacy rights may have been violated either by me or by those who are employed by me. A patient may file a complaint with me by simply providing me with a writing that specifies the manner in which he or she believes the violation occurred, the approximate date of such occurrence, and any details that he or she believes will be helpful to me. My contact information is:

Joanna Poppink, L.M.F.T.
10573 West Pico Boulevard #20
Los Angeles, CA 90064
Voice Phone: (310) 474-4165

I will not retaliate against a patient in any way for filing a complaint with me or with the Secretary. Patients must file complaints to the Secretary in writing. Patients can send complaints to the Secretary of the U.S Department of Health and Human Services. For California, the contact information is:

Region IX, Office for Civil Rights
U.S. Department of Health and Human Services
50 United Nations Plaza
Room 322
San Francisco, CA 94102.
Voice Phone (415) 437-8310.
FAX (415) 437-8329. TDD (415) 437-8311
http://www.hhs.gov/ocr/hipaahealth.txt

If a patient in my practice needs or desires further information related to this Notice or its contents or has any questions about this Notice or its contents, he or she can feel free to contact me. As the Contact Person for this practice, I will do my best to answer my patient's questions and to provide him or her with additional information.