Effective Date: April 14,
2003
NOTICE OF PRIVACY PRACTICES
THIS NOTICE OF PRIVACY PRACTICES DESCRIBES
HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices tells you
or your legal representative how I may use or
disclose your Protected Heath Information. It
also describes your rights and certain obligations
regarding the use and disclosure of Protected
Health Information.
I am required by law to make sure that Protected
Health Information that identifies you is kept
private, except as you authorize, or as laws
require or permit. I am required to give you
this Notice of Privacy Practices of my legal
duties and privacy practices with respect to
Protected Health Information about you and I
and my staff must follow the terms of the current
Notice of Privacy Practices.
HOW I MAY USE AND DISCLOSE YOUR PROTECTED
HEALTH INFORMATION.
The following describes ways that I may use
and disclose your Protected Health Information.
I will explain what I mean and try to give some
examples. Not every use or disclosure will be
listed. However, all of the ways I am permitted
to use and disclose Protected Health Information
will fall within one of the titles below. Please
note I am not required to obtain your permission
to use or disclose Protected Health Information
for treatment, payment or for Health Care Operations.
Treatment. I may use your
Protected Health Information to provide you
with treatment or services. I also may disclose
Protected Health Information to those who may
be involved in your care for continuity of care
purposes, i.e. your Primary Care Physician.
Payment. I may use and disclose
your Protected Health Information so that the
treatment or services you receive may be billed
and payment may be collected from an insurance
company, an Employee Assistance Program, a third
party, or from you, e.g., I may need to give
your health plan Protected Health Information
about treatment you received so your health
plan will pay me for it. I may also tell your
health plan about a proposed treatment plan
in order to receive to obtain prior authorization
Health Care Operations. I
may use and disclose your Protected Health Information
for Health Care Operation, i.e. uses and disclosures
necessary to operate the Psychotherapy and Counseling
Service. I may use your Protected Health Information
to review treatment to evaluate my performance.
I may remove Protected Health Information that
identifies you from your records so others may
use them for review of my performance.
Appointment Reminders. I may
use and disclose Protected Health Information
to contact you at the address you have provided
with regard to appointments at my office.
Treatment Alternatives. I
may use and disclose Protected Health Information
to recommend to you treatment options, e.g.
referrals to support groups.
Lawsuits and Disputes. If
you are involved in a lawsuit or a dispute,
I may disclose your Protected Health Information
in response to a court or administrative order.
I may disclose information in order to respond
to a lawsuit or to obtain malpractice insurance.
I may also disclose your Protected Health Information
in response to a subpoena, discovery request,
or other lawful process. In accordance with
California Law, efforts may be made to tell
you about the request for information or to
obtain an order to protect your Protected Health
Information.
Law Enforcement. I may release
your Protected Health Information if asked to
do so by a law enforcement official in response
to a court order, subpoena, warrant, summons
or similar process; to identify or locate a
suspect, fugitive, material witness, or missing
person. I may release information about the
victim of a crime if, under certain limited
circumstances, I am unable to obtain the victim’s
agreement. I may disclose information about
a death I believe may be the result of criminal
conduct; about criminal conduct at my office;
and in emergency circumstances to report a crime;
the location of the crime or victims; or the
identity, description or location of the person
who committed the crime
Coroners. Medical Examiners and Funeral
Directors. I may release your Protected
Health Information as required or compelled
by law to a coroner, medical examiner or funeral
director in the event of your death.
National Security and Intelligence
Activities. I may release your Protected
Health Information to authorized federal officials
for intelligence, counterintelligence, and other
national security activities authorized by law.
Protective Services for the President
of the United States and Others. I
may disclose your Protected Health Information
to authorized federal officials so they may
provide protection to the President, other authorized
persons or foreign heads of state or to conduct
special investigations.
As Required By Law. I may
disclose your Protected Health Information when
required to do so by federal, state or local
law.
To Avert a Serious Threat to Health
or Safety. I may use and disclose your
Protected Health Information when necessary
to prevent a serious threat to the health and
safety of the public or person. Any disclosure,
however, would only be to someone able to help
prevent the threat.
To Avert Danger to Yourself or Another.
Disclosure is compelled or permitted if you
are in such mental or emotional condition as
to be dangerous to your self or the person or
property of others, and if I determine that
disclosure is necessary to prevent the threatened
danger. I am required to disclose if you tell
me of a serious/imminent threat of physical
violence by you against a reasonably identifiable
victim or victims.
SPECIAL SITUATIONS
Military and Veterans. If
you are a member of the armed forces, I may
release your Protected Health Information as
required by military command authorities.
Workers’ Compensation. I may
release your Protected Health Information for
workers’ compensation or similar programs. These
programs provide benefits for work-related injuries
or illness.
Public Health Risks. I may
disclose your Protected Health Information for
public health activities. This generally includes
reporting the abuse or neglect of children,
elders or dependent adults. I may notify the
appropriate government authority or reporting
agency if I believe a client has been the victim
of abuse, neglect or domestic violence; but
only when required or authorized by law.
Marketing. I will not use or disclose information
for marketing.
In all cases use or disclosure of information
will be only that which is deemed minimally
necessary.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH
INFORMATION.
You have the following rights regarding
Protected Health Information I maintain about
you:
Right to Inspect and Receive a Copy.
You have the right to inspect or obtain a copy
of Protected Health Information that may be
used to make decisions about you. This includes
billing records but may not include some Protected
Health Information, i.e. psychotherapy notes.
You must submit your request in writing to my
administrator. If you request a copy of the
Protected Health Information, you may be charged
a fee.
I may deny your request to inspect and receive
a copy in certain very limited circumstances.
If you are denied access to your Protected Health
Information, you may request that the denial
be reviewed. I will review your request and
the denial and you will either receive a copy
or have a written response as to why you are
being denied.
Right to Amend. If you feel
that the Protected Health Information I have
about you is incorrect or incomplete, you may
ask me to amend the Protected Health Information.
To request an amendment, your request must be
made in writing to my administrator. In addition,
you must provide a reason to support the requested
amendment.
I may deny your request for an amendment if
it is not in writing or if it does not include
a reason supporting the request. I may deny
your request if you ask me to amend Protected
Health Information that was not made by me or
part of the Protected Health Information kept
by my office; is not part of the Protected Health
Information which you would be permitted to
inspect, (psychotherapy notes) and copy; or
is accurate and complete.
Even if I deny your request for amendment, you
have the right to submit a written addendum
with respect to any item or statement in your
record you believe is incomplete or incorrect.
If you ask in writing to make the addendum part
of your record, I will attach it to your records
and include it whenever I make a disclosure
of the item or statement you believe to be incomplete
or incorrect.
Right to a List of Disclosures.
You have the right to request a list of persons
or agencies to which I may have given your Protected
Health Information when authorized. This list
will not include my own use for Treatment, Payment
and Health Care Operations, or for other reasons
specified by laws.
To request this list of disclosures, you must
submit your request in writing to my administrator.
Your request must state a time period that may
not be longer than six years and may not include
dates before April 14, 2003. The first list
you request within a 12-month period will be
free. I may charge you for the costs of providing
additional lists.
Right to Request Limitations.
You have the right to request a limitation on
how I use or disclose your Protected Health
Information for your Treatment, Payment or our
Health Care Operations. You also have the right
to request a limit on the Protected Health Information
I disclose about you to someone else, like a
family member or friend, who may be involved
in your care or the payment for your care. To
request limitations, you must make your request
in writing on a Special Limits on the Use or
Disclosure of Protected Health Information Request
form. In your request, you must tell me (1)
what Protected Health Information you request
to limit; (2) whether you request to limit our
use, disclosure or both: and (3) to whom you
want the limits to apply, e.g., disclosures
to your spouse. I am not required to agree to
your request. If I do agree, I will comply with
your request unless the Protected Health Information
is needed to provide you emergency treatment.
If I do not agree, I will tell you the reason
I cannot comply with your request.
Right to Request Confidential Communications.
You have the right to request that I communicate
with you about mental health matters in a certain
way or at an alternative address. For example,
you might ask that I only contact you at work
or by mail. To request confidential or alternative
communications, you must make your request in
writing to my administrator. I will not ask
you the reason for your request. I will try
to accommodate all reasonable requests. Your
request must say how or where you wish to be
contacted.
Right to a Paper Copy of This Notice
of Privacy Practices. You have the
right to a paper copy of this Notice of Privacy
Practices. You may also access this Notice of
Privacy Practices at my website, http://www.milmorales.com.
CHANGES TO THIS NOTICE OF PRIVACY PRACTICES
I reserve the right to change this Notice of
Privacy Practices. I reserve the right to make
the revised or changed Notice of Privacy Practices
effective for your Protected Health Information
I already have about you as well as any Protected
Health Information I receive in the future.
I will post a dated copy of the current Notice
of Privacy Practices in the office and I will
either send you a copy of the revised Notice
or offer you one at the time of your next appointment.
COMPLAINTS
If you believe your privacy rights have been
violated, you may file a complaint with me or
with the Secretary of the Department of Health
and Human Services. To file a complaint with
me, or to find out how to contact the Secretary
of the Department of Health and Human Services
contact my administrator. All complaints must
be submitted in writing. You will not be penalized
for filing a complaint.
Administrator
2400 Sycamore Drive, Suite 19
Antioch, CA 94509
OTHER USES OF PROTECTED HEALTH INFORMATION
You may authorize disclosures of Protected
Health Information not covered by this Notice
of Privacy Practice or the law by signing a
Release to Use or Disclose Information form
specifying the information that you are authorizing
use of or disclosure and to whom you wish to
release this information.
You may revoke that permission, in writing,
at any time. If you revoke your permission,
I will no longer use or disclose Protected Health
Information about you for the reasons covered
by your written authorization, except if I have
already acted in reliance on your permission.
You understand that I am unable to take back
any disclosures I have already made with your
permission, and that I am required to retain
our records of the care that I provided to you
in accordance with the law.
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