The San Francisco Center for Compassion-Focused Therapies
465 California Street, Suite #660, San Francisco, CA 94104
(415) 234-0310 | firstname.lastname@example.org
Chia-Ying Chou, PhD (PSY#30161), director
Troy DuFrene, MA, SSC (RPA#94025675)
Joylee Huang, MA, EdM (#APCC7639)
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
- OUR PLEDGE REGARDING HEALTH INFORMATION:
We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. To monitor your progress in therapy, we may ask you to complete assessment scales or questionnaires. The record and assessment are important tools for us to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. It also describe your rights to the health information we keep about you and describes certain obligations we have regarding the use and disclosure of your health information. We are required by law to:
- Make sure that protected health information (“PHI”) that identifies you is kept private.
- Give you this notice of my legal duties and privacy practices with respect to health
- Follow the terms of the notice that is currently in
- We can change the terms of this Notice, and such changes will apply to all information we have about The new Notice will be available upon request.
- HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations:
Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’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. If we need to consult with another licensed health care provider, or a clinician were to consult with us about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist better provide care to you. Additionally, if your service provider is a pre-licensed clinician, he or she will discuss your case with his/her supervisor. That supervisor is bound by same privacy policies as your service provider.
Lawsuits and Disputes:
If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Research and Training
We conduct research and do writing and teaching for professional and lay audiences about anxiety, depression, and other psychological difficulties. If information about you is used in this context, we will take all reasonable efforts to protect your identity and will only use de-identified information about you. This means we will not include your name, address, or any other information that could identify you in research, training, or writing. If you would not like any of your information be used in this way, you have the right to not give your permission. This will not affect your treatment in any way. You will be asked about this in your first session, and you can withdraw your permission for us to use this information at any time over the course of the treatment.
- CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. We do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
- For our use in treating you
- For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy
- For our use in defending ourselves in legal proceedings instituted by you
- For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA
- Required by law and the use or disclosure is limited to the requirements of such law
- Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes
- Required by a coroner who is performing duties authorized by law; (h) required to help avert a serious threat to the health and safety of
As a psychotherapists, we will never use or disclose your PHI for marketing purposes or sell your PHI in the regular course of our business.
- CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR
Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:
- When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such
- For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or
- For health oversight activities, including audits and
- For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing
- For law enforcement purposes, including reporting crimes occurring on my
- To coroners or medical examiners, when such individuals are performing duties authorized by
- Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter- intelligence operations; or, helping to ensure the safety of those working within or housed in correctional
- For workers’ compensation Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
- Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I
- CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO
We 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, with your written permission. The opportunity to consent may be obtained retroactively in emergency situations.
- YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
- The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations We are not required to agree to your request, and we may say “no” if I believe it would affect your health care.
- The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in
- The Right to Choose How We Send PHI to You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
- The Right to See and Get Copies of Your Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost-based fee for doing so.
- The Right to Get a List of the Disclosures We Have Made to You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost-based fee for each additional
- The Right to Correct or Update Your If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.
- The Right to Get a Paper or Electronic Copy of this You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
- QUESTIONS / COMPLAINT PROCEDURE
- If you have a question about this policy or wish to make a complaint about a privacy-related issue, please contact:
Chia-Ying Chou, PhD: 465 California Street, Suite #660, San Francisco, CA 94104
(415) 234-0310 email@example.com
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on 06/26/2018