NOTICE OF PRIVACY PRACTICES - HIPAA

PROTECTING YOUR PRIVACY IS IMPORTANT TO US.

 

Notice of Clinicians’ Policies and Practices to Protect the Privacy of Your Protected Health Information (PHI)

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.

Youth Enterprise, Inc. ("YE"/ “Clinic” / "YE Clinic") may use or disclose your protected health information (PHI) for certain treatment, payment, and health care operations purposes without your authorization. In certain circumstances YE can only do so when the person or business requesting your PHI gives YE a written request that includes certain promises regarding protecting the confidentiality of your PHI. To help clarify these terms, here are some definitions:

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

“Treatment, Payment and Health Care Operations"

• Treatment is when YE or another healthcare provider diagnoses or treats you. An example of treatment would be when YE consults with another health care provider, such as your family physician or another psychologist, regarding your treatment.

 

• Payment is when YE obtains reimbursement for your healthcare. Examples of payment are when YE discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

 

• Health Care Operations is when YE disclose your PHI to your health care service plan (for example your health insurer), or to other health care providers contracting with your plan, or administering the plan, such as case management and care coordination.

 

“Use” applies only to activities within the YE office/ clinic, such as sharing, employing, applying, utilizing,examining, and analyzing information that identifies you.

“Disclosure” applies to activities outside of the YE office/ clinic, such as releasing, transferring, or providing access to information about you to other parties.

“Authorization” means your written permission for specific uses or disclosures.

YE may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances, when YE is asked for information for purposes outside of treatment and payment operations, YE will obtain an authorization from you before releasing this information. YE will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes YE has made about conversations during a private, group, joint, or family therapy session, which YE has kept separate from the rest of your medical record.

 

These notes are given a greater degree of protection than PHI.
You may revoke or modify all such authorizations (of PHI or psychotherapy notes) at any time; however, the revocation or modification is not effective until YE receives it.

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

 

Child Abuse: Whenever YE, in its professional capacity, have knowledge of or observe a child YE knows or reasonably suspects, has been the victim of child abuse or neglect, YE must immediately report such to a police department or sheriff’s department, county probation department, or county welfare department.
Also, if YE has 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, YE may report such to the above agencies.

 

Adult and Domestic Abuse: If YE, in its professional capacity, has observed or has 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 YE is told by an elder or dependent adult that he or she has experienced these or if YE reasonably suspects such, YE must report the known or suspected abuse immediately to the adult protective services agency or the local law enforcement agency.

 

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

 

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that YE has provided you, YE must not release your information without 1) your written authorization or the authorization of your attorney or personal representative; 2) a court order; or 3) a subpoena duces tecum (a subpoena to produce records) where the party seeking your records provides YE with a showing that you or your attorney have been served with a copy of the subpoena, affidavit and the appropriate notice, and you have not notified YE that you are bringing a motion in the court to quash (block) or modify the subpoena. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. YE will inform you in advance if this is the case.

 

Serious Threat to Health or Safety: If you or your family member communicate to YE that you pose a serious threat of physical violence against an identifiable victim, YE must make reasonable efforts to communicate that information to the potential victim and the police. If YE has reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, YE may release relevant information as necessary to prevent the threatened danger.

 

Worker’s Compensation: If you file a worker’s compensation claim, YE may disclose to your employer your medical information created as a result of employment-related health care services provided to you at the specific prior written consent and expense of your employer so long as the requested information
is relevant to your claim provided that is only used or disclosed in connection with your claim and describes your functional limitations provided that no statement of medical cause is included.

PATIENT'S RIGHTS

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, YE is 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 receiving services at YE. Upon your request, YE will send your bills to another address.)
• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and/or psychotherapy notes in YE’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. YE may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, YE will
  discuss with you the details of the request and denial process.
• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. YE may deny your request. On your request, YE 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 PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, YE 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 YE upon request, even if you have agreed to receive the notice electronically.

 

CLINICIAN'S DUTIES

YE is required by law to maintain the privacy of PHI and to provide you with a notice of YE’s legal duties and privacy practices with respect to PHI.


YE reserves the right to change the privacy policies and practices described in this notice. Unless YE notifies you of such changes, however, YE is required to abide by the terms currently in effect. If YE revises its policies and procedures, YE will notify you.

If you have questions about this notice, disagree with a decision YE has make about access to your records, or have other concerns about your privacy rights, you may contact Dr. Alina C. Whitmore, Psy.D., our HIPAA Compliance Officer.

 

If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint to the same person as above.

 

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

 

You have specific rights under the Privacy Rule. YE will not retaliate against you for exercising your right to
file a complaint.

This notice will go into effect on October 1st, 2021. YE reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that YE maintains. YE will provide you with a revised notice.

 

By signing below, you acknowledge that you have received a copy of YE’s HIPAA notice. You understand that if you have questions or complaints regarding YE’s privacy rights that you may contact Dr. Alina C. Whitmore, HIPAA Compliance Officer.

 

You further understand that YE will offer you updates to this notice should it be amended, modified, or changed.

By signing below, you acknowledge and attest to the following:

1. That you consent to this Notice of Privacy Practices.
2. That you have reviewed, fully understand, and agree to the terms, conditions, and policies outlined in this document.
3. That you agree to hold YE, the Clinic, and any members of the clinical team free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from services provided.
4. If client is a minor, I attest that I am client's Parent/ Legal Guardian and have the legal authority to sign this document on client's behalf, consenting to the contents outlined herein.