CALIFORNIA NOTICE FORM
Notice of Privacy Practices
This notice describes how health/mental health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this notice, or if you desire additional information about our privacy policies, please contact the Privacy Officer, Matthew Mak at (626) 577-8480.
- Disclosures for Treatment, Payment, and Health Care Operations
Heritage Clinic is committed, whenever possible, to keep the health/mental health information contained in your record private.
Heritage Clinic may, however use or disclose your health/mental health information, for certain treatment, payment, and health care operations purposes without your authorization. In certain circumstances Heritage Clinic, can only do so when the person or business requesting your health/mental health information gives your clinician a written request that includes certain promises regarding protecting the confidentiality of your health/mental health information. To help clarify these terms, here are some definitions:
- “Protected Health Information (PHI)” refers to information in your health/mental health information in your record that could identify you.
- “Treatment and Payment Operations”
-Treatment is when your clinician or another healthcare provider diagnoses or treats you. An example of treatment would be when your clinician consults with another health care provider, such as your family physician or another clinician, regarding your treatment.
-Payment is when we obtain reimbursement for your healthcare. Examples of payment are when Heritage Clinic discloses your health/mental health information to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
-Health Care Operations is when Heritage Clinic discloses your health/mental health information to your health care service plan (for example your health insurer), or to your other health care providers contracting with your plan, for administering the plan, such as case management and care coordination.
- “Use” applies only to activities within Heritage Clinic such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
- “Disclosure” applies to activities outside of Heritage Clinic such as releasing, transferring, or providing access to information about you to other parties.
- “Authorization” means written permission for specific uses or disclosures.
- Uses and Disclosures Requiring Authorization
Heritage Clinic may use or disclose health/mental health information for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances, when Heritage Clinic is asked for information for purposes outside of treatment and payment operations, we will obtain an authorization from you before releasing this information. Heritage Clinic will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes your clinician made about your conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than other protected health/mental health information (PHI).
You may revoke or modify all such authorizations (of health/mental health information or psychotherapy notes) at any time; however, the revocation or modification is not effective until we receive it.
III. Uses and Disclosures with Neither Consent nor Authorization
We are required by law to maintain the privacy of your protected health information. However, there are some situations where we may use or disclose Health/Mental Health Information without your consent:
- Child Abuse: Whenever we have knowledge of or observe a child we know or reasonably suspect, has been the victim of child abuse or neglect, we must immediately report such to a police department or sheriff’s department, county probation department, or county welfare department. Also, if we have knowledge of or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional well‑being is endangered in any other way, we may report such to the above agencies.
- Adult and Domestic Abuse: If we have observed or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if we are told by an elder or dependent adult that he or she has experienced these or if we reasonably suspect such, we must report the known or suspected abuse immediately to the local Adult Protective Services, Long-term care Ombudsman, a law enforcement agency, or other appropriate agency.
- Health Oversight: If a complaint is filed against Heritage Clinic with a state administrative agency, that agency may have the authority to demand/receive certain kinds of health information about you that is relevant to the complaint.
- Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that we have provided you, we may release your information upon the receipt of 1) a court order; or 2) a valid subpoena. We may also have to provide information if the evaluation is court-ordered. We will make every effort to keep you informed about these situations.
- Serious Threat to Health or Safety: If you communicate to us a serious threat of physical violence against an identifiable victim, we must make reasonable efforts to communicate that information to the potential victim and the police. If we have reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, we may release relevant information as necessary to prevent the threatened danger.
- Appointment Reminders: We may use/disclose your health/mental health information to contact you as a reminder that you have as appointment (for example, if you have an appointment with a psychiatrist, our support staff may contact you for the day before as a reminder). If you do not wish us to contact you for appointment reminders, please provide the Privacy Officer with alternative instructions, in writing.
- For Research Purposes: In certain circumstances, we may use/disclose your health/mental health information to our research staff and their designees in order to assist psychiatric/psychological research. If you would like this use/disclosure to be limited, please inform the Privacy Officer of this, in writing.
All other uses or disclosures not mentioned above with only be made with your authorization.
- Patient’s Rights and Psychologists Duties
- Right to Request Restrictions ‑You have the right to request restrictions on certain uses and disclosures of health/mental health information about you. However, we are not required to agree to a restriction you request.
- Right to Receive Confidential Communications by Alternative Means and at Alternative Locations ‑ You have the right to request and receive confidential communications of health/mental health information by alternative means and at alternative locations. (For example, you may not want a family member to know that you are being seen at Heritage Clinic. Upon your request, we could send your bills to another address.)
- Right to Inspect and Copy ‑ You have the right to inspect or obtain a copy (or both) of health/mental health information in our mental health and billing records used to make decisions about your case for as long as the health/mental health information is maintained in the record. We may deny your access to health/mental health information under certain circumstances, but in some cases you may have this decision reviewed. On your request, your clinician will discuss with you the details of the request and denial process.
- Right to Amend ‑ You have the right to request an amendment of health/mental health information for as long as the health/mental health information is maintained in the record. Heritage Clinic may deny your request. On your request, your clinician will discuss with you the details of the amendment process.
- Right to an Accounting ‑ You generally have the right to receive an accounting of disclosures of health/mental health information for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, your clinician will discuss with you the details of the accounting process.
- Right to a Paper Copy ‑ You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.
- Right to be Notified of Security Breaches – Affected individuals will be notified following a breach of unsecured protected health information.
Heritage Clinic’s Duties:
- Heritage Clinic is required by law to maintain the privacy of health/mental health information and to provide you with a notice of our legal duties and privacy practices with respect to health/mental health information.
- Heritage Clinic reserves the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
Signature of conservator (if appropriate):_ _____________________________________________________
This notice will go into effect on April 1, 2013.
If you are concerned that Heritage Clinic has violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact our Privacy Officer at (626) 577-8480.
hcadministratorDecember 17th, 2020 View Profile