I. 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.

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II. IT IS MY LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (“PHI”).

 

By law I am required to insure that your PHI is kept private. The PHI constitutes information created or noted by me that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. I am required to provide you with this Notice about my privacy procedures. This Notice must explain when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, or analyze information within my practice; PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside my practice. With some exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, I am always legally required to follow the privacy practices described in this Notice.

 

Please note that I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI already on file with me. Before I make any important changes to my policies, I will immediately change this Notice and post a new copy of it in my office. You may request a copy of this Notice from me or you can view a copy of it in my office.

 

III. HOW I WILL USE AND DISCLOSE YOUR PHI.

 

I will use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization, others will not. Below you will find the different categories of my uses and disclosures.

 

A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Written Consent. I may use and disclose your PHI without your consent for the following reasons:

 

1. For Treatment. I may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who either provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treating you I may disclose your PHI to her/him in order to coordinate your care.

 

2. For Health Care Operations. I may disclose your PHI to facilitate the efficient and correct operation of my practice. Examples: Quality control - I might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. I may also provide your PHI to my attorneys, accountants, consultants, and others to make sure that I am in compliance with applicable laws.

 

3. To Obtain Payment for Treatment. I may use and disclose your PHI to bill and collect payment for the treatment and services I provided. Example: I might send your PHI to your insurance company or health plan in order to get payment for the services that I have provided to you. I could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for my office.

 

4. Incapacitation or Emergency. I may disclose your PHI to others without your consent if you are incapacitated or if an emergency exists. Examples: Your consent isn’t required if you needs emergency treatment provided that I attempt to get your consent after treatment is rendered, or if I try to get your consent but you are unable to communicate with me and I think you would consent to such treatment if you were able to do so.

 

B. Certain Other Uses and Disclosures Do Not Require Your Consent. I may use and/or disclose your PHI without your consent or authorization for the following reasons:

 

1. When federal, state or local laws require disclosure. Example: I may have to make a disclosure to applicable government officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect.

 

2. When judicial or administrative proceedings require disclosure. For example, I have to use or disclose your PHI in response to a subpoena.

 

3. When law enforcement requires disclosure. Example: I may have to disclose your PHI in response to a search warrant.

 

4. When public health activities require disclosure. Example: I may have to disclosure your PHI to report to a government official an adverse reaction that you had to a medication.

 

5. When health oversight activities require disclosure. Example: I may have to provide information to assist the government in conducting an investigation or inspection of a health care provider or organization.

 

6. To avert a serious threat to health or safety. If disclosure is compelled or permitted by the fact that you are in such an emotional or mental condition as to be dangerous to yourself or to the person or property of others. Example: I may have to disclose your PHI to avert a serious threat to the health or safety of others. However, any such disclosure will only be made to someone able to prevent the threatened harm from occurring.

 

7. If disclosure is compelled or permitted by the fact that you tell me of a serious/imminent threat of physical violence by you against a reasonable identifiable victim or victims.

 

8. If disclosure is mandated by the California Child Abuse and Neglect Reporting law. For example, if I have a reasonable suspicion of child abuse or neglect.

 

9. If disclosure is mandated by the California Elder/ Dependent Adult Abuse Reporting law. For example, if I have a reasonable suspicion of elder abuse or dependent adult abuse.

 

10. Appointment reminders and health related benefits or services. Examples: I may use your child’s PHI to provide appointment reminders. I may use PHI to give you information about alternative treatment options, or other health care services or benefits that may be of interest to you.

 

11. If an arbitrator or arbitration panel compels disclosure. When arbitration is lawfully requested by either party, pursuant to subpoena duces tecum (e.g., a subpoena for mental health records) or with any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.

 

12. If disclosure is otherwise specifically required by law.

 

C. Certain Uses and Disclosures Require You to Have the Opportunity to Object.

 

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment of your health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations.

 

D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections IIIA, IIIB, and IIIC above, I will request you 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 such an authorization in writing to stop any future uses or disclosures (to the extent that I haven’t taken any action in reliance on such authorization) of your PHI by me.

 

IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI

These are your rights with respect to your child’s PHI:

 

A. The Right to Request Restrictions. You have the right to request restrictions or limitations on my uses or disclosures of your PHI to carry out my treatment, payment, or health care operations. You also have the right to request that I restrict or limit disclosures of your PHI to family members or friends involved in your care or who are  financially responsible for your care. Please submit such requests to me in writing. I will consider your requests, but I am not legally required to accept them. If I do accept your requests, I will put them in writing and I will abide by them, except in emergency situations. However, be advised, that you may not limit the uses and disclosures that I am legally required to make.

 

B. The Right to Inspect and Receive a Copy of Your PHI. In most cases, you have the right to inspect and receive a copy of the PHI that I have on you, but you must make the request to inspect and receive a copy of such information in writing. If I do not have your PHI, but I know who does, I will tell you how to get it. I will respond to your request within 30 days of receiving your written request. In certain situations, I may deny your request. If I do, I will tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed. If you request copies of your PHI, I will charge you not more than $.25 per page. Instead of providing the PHI you requested, I may provide you with a summary or explanation of your PHI as long as you agree to that and the cost in advance.

 

C. The Right to Receive Confidential Communications by Alternative Means and at Alternative Locations. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). Upon your request, I will send your billing statements to another address.

 

D. The Right to receive a List of the Disclosures I have Made. You have the right to receive a list of instances, i.e., and Accounting of Disclosures, in which I have disclosed your PHI. The list will not include disclosures made for my treatment, payment, or health care operations; disclosures made to you; disclosures you authorized; disclosures incident to a use or disclosure permitted or required by the federal privacy rule; disclosures made for national security or intelligence; disclosures made to correctional institutions or law enforcement personnel. I will respond to your request for an Accounting of Disclosures within 60 days of receiving such a request. The list I will give you will include disclosures made in the last 6 years unless you request a shorter time. The list will include the date the disclosure was made, to whom the PHI was disclosed, and the reason for the disclosure. I will provide the list to you at no charge, but if you make more than one request in the same year, I may charge you a reasonable, cost-based fee for each additional request.

 

E. The Right to Amend Your Child’s PHI. If you believe there is a mistake in your PHI or that a piece of important information is missing, then you have a right to request that I correct the existing information or add the missing information. You must provide the request and your reason in writing. I will respond within 60 days of receiving your request to correct or update your PHI. I may provide a written denial of your request under certain circumstances, in which case you have the right to file a disagreement with my denial or request that your initial request and my subsequent denial are 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.

 

F. Right to a Paper Copy. You have the right to obtain a paper copy of this notice from me upon request, even if you originally agreed to receive the notice electronically.

 

V. COMPLAINTS

If you are concerned that I have violated your privacy rights, or you disagree with

a decision I made about access your child’s records, you may contact me at:

 

Celine M. Paganini Psychotherapy, Inc.

322 S Padre Juan Ave

Ojai, CA 93023

(323) 380-0017

 

You may also send a written complaint to the Secretary of the U.S. Department of

Health and Human Services at 200 Independence Ave S.W., Washington, D.C. 20201.

 

VI. EFFECTIVE DATE OF THIS NOTICE

This notice went into effect December 2020.