Etta Bergstresser LCSW Mental Health Therapy Eureka Humboldt

Notice of Policies and Practices to Protect

the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU

MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

1. Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

PHI refers to information in your health record that could identify you.

Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician, social worker, therapist, psychologist, or psychiatrist.

Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

Use applies only to activities within my office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

Disclosure applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties.

2. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances, I will obtain an authorization from you before releasing this information. With your verbal permission, I may also disclose your information to a family member(s) who are directly involved in your treatment. You may revoke all such authorizations at any time, provided each revocation is in writing.

3. Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse: If I have cause to believe that a child has been, or may be, abused or neglected, I must by law make a report of such immediately to a Police Department, Sheriff’s Office, or County Child Welfare Services agency.

Elderly or Disability Abuse: If I have cause to believe that an elderly (65 years) or disabled person is in a state of abuse, neglect, or exploitation, I must immediately report such to a Police Department, Sheriff’s Office, or County Adult Protective Services agency.

Serious Threat to Health or Safety: If I have cause to believe that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, I may disclose relevant confidential mental health information to medical or law enforcement personnel.

Abuse by a Therapist: If I have cause to believe that you have been the victim of sexual exploitation by a mental health professional during the course of treatment, I will report this to the appropriate State Licensing Board.

Health Oversight: If a complaint is filed against me with the California Board of Behavioral Sciences, that entity has the authority to subpoena confidential mental health information from me relevant to that complaint.

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information, without written authorization from you or your personal or legally appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered.

Worker’s Compensation: If you file a worker's compensation claim, I may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.

4. Client Rights

You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your request in writing.

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am 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 PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send information to another address.)

Right to Inspect and Copy: You have the right to inspect and/or obtain a copy of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.

Right to Amend: If you believe the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am not required to agree to the amendment.

Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.

Right to a Copy of this Notice: You have the right to a copy of this notice from me upon request.

5. My Duties

I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

If I revise my policies and procedures, I will provide you a revised copy at your next visit or by mail.

6. Complaints

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, please discuss your concerns with me. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Information on filing such a complaint can be found at https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html or I can provide you with the appropriate address upon request.

7. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect immediately. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice at your next visit or by mail.