Protected Health Information
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
I am legally required to protect the privacy of your Protected Health Information (PHI), which includes information that can be used to identify you that I’ve created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of this health care. I must provide you with this Notice about my privacy practices, and such Notice must explain how, when, and why I will “use” and “disclose” your PHI. A “use” of PHI occurs when I share, examine, utilize, apply, or analyze such information within my practice; PHI is “disclosed” when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of my practice.
You can request a copy of this Notice from me, or you can view a copy of it in my office.
1. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent:
For treatment: I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your care.
To obtain payment for treatment: I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. I may also provide your PHI to billing companies, claims processing companies, and others that process my health care claims.
For health care operations: I can disclose your PHI evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. I may also provide your PHI to accountants or attorneys to make sure I am complying with applicable laws.
Other disclosures: I may disclose your PHI if you need emergency treatment, as long as I try to get your consent after treatment is rendered.
2. Certain Uses and Disclosures Do Not Require Your Consent:
When disclosure is required by federal, state or local law; judicial or administrative proceedings; or, law enforcement: For example, I may make a disclosure to applicable officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect, or when ordered in a judicial or administrative proceeding.
For public health activities: For example, I may have to report information about you to the county coroner.
For health oversight activities: For example, I may have to provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization.
For research purposes: In certain circumstances, I may provide PHI in order to conduct medical research.
To avoid harm: In order to avoid a serious threat of harm, I may disclose PHI to law enforcement personnel or persons able to prevent or lessen such harm.
For specific government functions: I may disclose PHI of military personnel and veterans in certain situations and for national security purposes, such as protecting the President of the United States or conducting intelligence operations.
For workers’ compensation: I may provide PHI in order to comply with workers’ compensation laws.
Appointment reminders and health related benefits or services: I may use PHI to provide appointment reminders or inform you of treatment alternatives, or other health care services or benefits I offer.
3. Opportunity to Object — Certain Uses and Disclosures Require You to Have the Opportunity to Object:
I 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.
4. Written Authorization — Other Uses and Disclosures Require Your Prior Written Authorization:
In any other situation not described above, I will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke it in writing to stop any future uses and disclosures of your PHI by me.
Rights You Have Regarding Your PHI
Limits on Uses and Disclosures: You have the right to ask that I limit uses and disclosures of your PHI. I will consider your request, but am not legally required to accept it. If I accept your request, I will abide by them except in emergency situations. You may not limit the uses and disclosures that I am legally required or allowed to make.
How I Send PHI to You: You have the right to ask that I send information to you to at an alternate address or by alternate means (e.g., e-mail instead of regular mail). I must agree if I can easily provide the PHI to you in the format you requested.
Copies of Your PHI: In most cases, you have the right to see or receive copies of your PHI. Your request must be in writing. I will respond to you within 30 days of receiving your written request. If I deny your request, I will explain why, in writing and tell you how to have my denial reviewed. If you request copies of your PHI, I will charge you not more than $.25 for each page. I may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance.
Right to a List of Disclosures: You have the right to a list of instances in which I have disclosed your PHI. The list will exclude uses or disclosures to which you have already consented; or uses and disclosures made for national security purposes, to law enforcement personnel, or disclosures made before April 15, 2003. I will respond to your request within 60 days of receiving it. The list will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed, a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no charge, but for more than one request per year, I will charge you a reasonable cost-based fee for each additional request.
Right to Correct PHI: If you believe that there is a mistake in your PHI or that important information is missing, you have the right to request that I make a correction or add the missing information. You must provide the request in writing. I will respond within 60 days of receiving your request to correct or update. I may deny your request in writing if the PHI is correct and complete; not created by me; not allowed to be disclosed, or not part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don’t file one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If I approve your request, I will make the change to your PHI, tell you that I have done it, and tell others that need to know about the change to your PHI.
This Notice by E-Mail: You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy of it.
How to Complain: If you think I may have violated your privacy rights, or disagree with a decision I made about access to your PHI, you may file a complaint with the person listed below. You also may send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. I will take no retaliatory action against you if you file a complaint about my privacy practices.
Person to Contact: If you have any questions or complaints about this notice or my privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact:
Rosie Clark, manager.
Wilshire/Valley Therapy Center and Administration Services
16250 Ventura Blvd., Suite 465
Encino, CA 91436
818 906-0406 ext. 1
View the web site privacy policies