Questions or concerns? Call (877) 611-CASA(2272)
At Casa de la Familia, we pride ourselves in being a team of professionals working to ensure you quality services.
As a patient, you should have an expectation to receive benefits from psychotherapy, however, there is no guarantee these benefits will occur. Unlike a visit to the medical doctor, psychotherapy calls for an active effort on your part. Consistent attendance, as well as working on topics spoken about in sessions at home will provide you with the maximum benefits possible.
Therapy often involves discussing unpleasant aspects of your life; therefore, you may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness. If these emotions should occur, remember that psychotherapy has been shown to have benefits for people who complete it, and be sure to speak with your therapist about it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Due to the varying nature and severity of problems and the individuality of each client, it is not possible to predict or guarantee a specific outcome or result of therapy.
Your first handful of sessions will consist of you and your therapist getting to know one another. By the end of this time, your therapist will have compiled a treatment plan, including the optimal frequency of your visits. During this time, both you and your therapist will both decide if he/she is the best person to provide the services you need in order to meet your treatment goals. Should you have any concerns, please contact your case manager or your therapist in order to attend to your needs. Therapy involves your commitment of time and energy; therefore, it is best that you feel comfortable with the therapist you select.
Should you need to reschedule or cancel an appointment, you may call (887) 611-2272. In case of a crisis please call our offices, and you will either be connected to your therapist or another on call clinician.
As a patient, you have the right to:
As a patient, you have the responsibility to:
THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Your clinician will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Your clinician may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results.
SCOPE OF PRACTICE: During the course of therapy, your clinician is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational.
TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, Casa de la Familia will discuss with you his/her working understanding of the problem, treatment plan, therapeutic objectives, and his/her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, your clinicians expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.
TERMINATION: As set forth above, after the first couple of meetings, Casa de la Familia will assess if he can be of benefit to you. Casa de la Familia’s does not work with clients who, in his opinion, he cannot help. In such a case, if appropriate, he will give you referrals that you can contact. If at any point during psychotherapy Casa de la Familia’s either assesses that he is not effective in helping you reach the therapeutic goals or perceived you as non-compliant or non-responsive, and if you are available and/or it is possible and appropriate to do, he will discuss with you the termination of treatment and conduct pre-termination counseling. In such a case, if appropriate and/or necessary, he would give you a couple of
referrals that may be of help to you. If you request it and authorize it in writing, Casa de la Familia’s will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, Casa de la Familia’s will give you a couple of referrals that you may want to contact, and if he has your written consent, he will provide her or him with the essential information needed. You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, Casa de la Familia’s will provide you with names of other qualified professionals whose services you might prefer.
Termination of Therapy and Duty of Care
Please let your therapist or administration know if you choose to terminate therapy. You are free to terminate whenever you like, however, it will be most beneficial to you and your therapist have a chance to review your goals and progress together. If you miss more than three scheduled sessions in a row without contact, or if you fail to schedule an appointment for a period of four weeks, it will be assumed that you have either terminated or taken a break from therapy. In this case, the duty of care responsibilities inherent in the therapist-client relationship will no longer be in effect, and will resume should you decide to return to therapy. You are welcome to return to therapy at any time in the future when it fits your needs or situation.
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.
WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to Casa de la Familia that the client presents a danger to others.
Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Casa de la Familia.
In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Casa de la Familia's clinical teams will use their clinical judgment when revealing such information.
Casa de la Familia will not release records to any outside party unless authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client, unless required by law. While Casa de la Familia will attempt to seek your authorization to release the requested information regarding psychotherapy from you first, in some situations a judge can order the release of the records of your psychotherapy with Casa de la Familia, or may order a representative of Casa de la Familia to testify in regard to our therapeutic work.
EMERGENCY: If there is an emergency during therapy, or in the future after termination, where a representative of Casa de la Familia becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, s/he will do whatever s/he can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, a representative may also contact the person whose name you have provided on this packet.
HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP or program pay source in order to process the claims. If you so instruct Casa de la Familia, only the minimum necessary information will be communicated to the carrier. Casa de la Familia has no control over, or knowledge of, what insurance companies do with the information submitted, or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and may be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.
LITIGATION: Sometimes patients become involved in litigation while they are in therapy or after therapy has been completed. Sometimes patients (or the opposing attorney, in a legal case) want the records disclosed to the legal system. Due to the nature of the psychotherapeutic process and the fact that it often involves making a full disclosure with regard to many matters, clients’ records are generally confidential and private in nature. Patients should know that very serious consequences can result from disclosing therapy records to the legal system. Such disclosures may negatively affect the outcome of custody disputes or other legal matters and may negatively affect the therapeutic relationship. If you or the opposing attorney are considering requesting Casa de la Familia's disclosure of the records, your clinician, or a clinical representative of Casa de la Familia will do his/her best to discuss with you the risks and benefits of doing so. As noted in this document, you have the right to review your own psychotherapy records anytime. (See also relevant section above: "WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW")
CONSULTATION: Casa de la Familia's clinicians consult regularly with other professionals within Casa de la Familia regarding clients. Should clinical consultation be required outside of the organization, each client's identity remains completely anonymous and confidentiality is fully maintained.
E–MAILS, CELL PHONES, TEXTS, COMPUTERS, AND FAXES: Computers and unencrypted e-mail, texts, and e-faxes communication can be relatively easily accessed by unauthorized people and therefore can compromise the privacy and confidentiality of the information used in such communications. Servers and telecommunication companies often have direct and unlimited access to all the information contained in the e-mails, texts and e-faxes that use their services. To protect the confidential information of clients, Casa de la Familia's programs are HIPPA compliant. When you communicate with Casa de la Familia using unencrypted e-mail, texts or e-fax or via phone messages, you assume the responsibility of the risk that your information and identity may be intercepted. If you choose to communicate with Casa de la Familia using e-mail or SMS/text messaging, you are advised to use personal email and SMS/MMS addresses rather than those associated you’re your work accounts. Please do not use texts, e-mail, voice mail, or faxes for emergencies as they will not be accessed in a timely manner.
RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of Casa de la Familia’s profession require that records be kept for at least 7 years. Please note that clinically relevant information from emails, texts, and faxes are part of the clinical records. Unless otherwise agreed to be necessary, Casa de la Familia’s retains clinical records only as long as is mandated by California state law. If you have concerns regarding the treatment records, please discuss them with a representative of Casa de la Familia. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when Casa de la Familia assesses that releasing such information might be harmful in any way. In such a case, Casa de la Familia’s will provide the records to an appropriate and legitimate mental health professional of your choice.
Considering all of the above exclusions, if it is still appropriate, and upon your request, Casa de la Familia’s will release information to any agency/person you specify unless Casa de la Familia’s assesses that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, Casa de la Familia will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.
Payment for Services
Casa de la Familia is committed to assisting you in qualifying for partnering programs, which requires your assistance and cooperation. You may be asked to sign additional forms, along with obtain copies of legal reports in order for you to qualify. It is important to note that it is possible to become ineligible for benefits. Some reasons you may be disqualified from the program are because:
In the event that any of these occur, please notify your therapist and case manager, as you may be responsible for all charges due relating to your services. Please contact your case manager should you have any questions or concerns.
The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.
TELEPHONE & EMERGENCY PROCEDURES: In case of an emergency, call 911. If you need to contact your clinician in between between sessions, please call 877-611-2272. Please do not use email or faxes for emergencies.
PAYMENTS & INSURANCE REIMBURSEMENT: Should you be enrolled in a pay for service program, clients are expected to pay the standard fee listed on this packet per 50-60 minute session. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify Casa de la Familia’s if any problems arise during the course of therapy regarding your ability to make timely payments.
Clients who have tertiary pay source should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, Casa de la Familia’s will provide you with a copy of your receipt, which you can then submit to your insurance company for reimbursement, if you so choose. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, Casa de la Familia’s can use legal or other means (courts, collection agencies, etc.) to obtain payment.
SOCIAL MEDIA POLICY
Casa de la Familia’s takes issues of confidentiality and privacy, as well as healthy boundaries relating to the therapeutic relationship, very seriously. In order to protect the right of client and therapist for privacy, in order to safeguard the confidentiality of information shared between them, and in order to avoid confusion and maintain clear boundaries between client and therapist,
Casa de la Familia representatives do not engage with clients in any way on social networking sites. For example, friend requests on Facebook will be denied and any communication on social platforms such as Messenger, will be ignored.
Casa de la Familia has active Facebook, Instagram, Linkedin, Twitter accounts as part of a professional practice, which aim to share
updates and blog posts. Clients are not expected to follow these accounts.
Clients should avoid connecting via social media to communicate matters related to your care. All matters regarding your care should be communicated by phone (877)611-CASA (2272).
Session Length & Cancellation Policy
A one hour psychotherapy session can take around 50 minutes. Your therapist has made room for you in his/her schedule; therefore at least a 24-hour notification is needed to cancel your appointment.
If the office is not notified about cancellation of appointment with at least 24 hour notice, the missed appointment will be considered a no show. At the third no show, services will be suspended. In order to re-enroll in services, you will need to sign a reinstatement letter.
Social Services Program After the third no show, service are suspended, and your social worker has 10 days to reinstate treatment, if no reinstatement is received, your referral will be terminated.
Services Not Provided
It is important to note that neither Casa de la Familia nor its representatives provide custody evaluation recommendations or legal advice, as these activities do not fall within the scope of Casa de la Familia’s practice.
Therapy never involves sexual or any other dual relationship that impairs your objectivity, clinical judgment or can be exploitative in nature.
I hereby agree to give consent for treatment to my assigned clinician and affiliated clinicians with Casa de la Familia. All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law. However, disclosure is required by law in the following circumstances:
No disclosures will be made without your or your legal guardian’s written permission. It is important to note that at Casa de la Familia, we are unable to provide services to those who are in need of inpatient services, as well as those who have long-term disorders and alcohol/addiction issues. Should your therapist determine that he/she is unable to continue services, he/she will refer you to an appropriate service provider in order for you to receive the appropriate services for your needs.
Upon enrollment of services for your minor at Casa de la Familia, you consent to give up access to records of their services with Casa de la Familia. Instead, general information about their treatment will be communicated upon request.
If appropriate, your child(ren)s clinician may contact you to be involved in treatment if your clinician feels that there is a high risk that you will seriously harm yourself or another/others.
I hereby give consent to Casa de la Familia's clinicians to conduct psychotherapy with the child named in this packet. I confirm that I am the parent/guardian to the child named in this packet. I consent that all material discussed during the psychotherapy sessions is confidential and can be released only with the permission of the minor in therapy. I understand special sensitivity may be required in releasing information about certain topics such as drugs and sex. I will accept Casa de la Familia's judgment in regard to releasing or sharing information obtained during the course of psychotherapy with the minor that may endanger or jeopardize the client's wellbeing.
In group therapy, it is of utmost important that all members maintain confidentiality and neither disclose the content of sessions nor the identity of fellow group members. It is highly recommended that any meaningful exchange outside the group also be discussed in the group. In group therapy, the other members of the group are not therapists.
They are not regulated by the same ethics and laws that bind your therapist. The limits of confidentiality and the reporting laws have been outlined earlier in this document. While the expectation is that all group members will maintain confidentiality regarding anything said in the group, you cannot be certain that they will. You are ultimately responsible for what you say and what you think, feel, or do with the feedback you receive in the group.
I hereby assign my insurance benefits to be made directly to Casa de la Familia for services rendered. I hereby attest that the information provided is accurate and I am an eligible member and understand that I am responsible for knowing my benefits/coverage. I will be financially responsible for all charges that are not covered by my pay source listed above. I hereby authorize the release of all information to other the pay source listed above, as well as affiliated entities, on request for the purpose of payment of the services provided, and further treatment of care by another physician. By providing my email address, I am electing to receive email communication from Casa de la Familia. I further agree that a photocopy of this agreement shall be as valid as the original. Payment is due at the time services are rendered. All charges are the direct responsibility of he client. If Casa de la Familia has problem collecting payment from you, attorney fees, collection agency costs and related fees will be added to your bill.
Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, the patient agrees that neither the patient nor the patient's attorney nor anyone else acting on the patient's behalf will call on the service provider nor the therapist delivering psychotherapy services to become a witness to testify in court, communicate with child custody evaluator/s, or any other proceeding, or request a disclosure of the psychotherapy records.
If you are under eighteen years of age, please be aware that the law may give your parents or guardians the right to obtain information about your treatment and/or examine your treatment records. It is Casa de la Familia's policy to request a written agreement from your parents or guardians indicating that they consent to give up access to such information and/or, to your records.
If they agree, Casa de la Familia will provide them only with general information about our work together subject to your approval, or, if Casa de la Familia feels it is important for them to know in order to make sure that you and people around you are safe.
If Casa de la Familia thinks it is appropriate, Casa de la Familia will involve them if Casa de la Familia feels that there is a high risk that you will seriously harm yourself or another/others. Before giving them any verbal or written information, Casa de la Familia will discuss the matter with you, if possible. Casa de la Familia will do it's best to resolve any differences that you may have about what I am prepared to discuss.
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompletely rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceeding. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence, giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physicians partner, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party.
Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator; together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.
Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure Section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.
Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations or (2) the claimant fails tor pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.
Article 5: Revocation: This agreement may be revoked by written notice delivered to physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:
The agreement is effective on date of first services. If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other person.
Consulting with clients over the phone or via text or email rather than in person (face-to-face) in the office brings additional complexities and potential disadvantages to the therapeutic process. When appropriate, Casa de la Familia may recommend that the client/s first choice is to find a local therapist with whom the client/s can meet face to face.
The patient, or guardian, hereby consents to engage in Telehealth visits with a Casa de la Familia therapist.
Usage: Telehealth allows you to talk to your provider by phone, computer, or tablet. At times, you use video so you and your provider can see each other. I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy/Video therapy session.
Benefits: Telehealth allows you to not go to a clinic or hospital to see your provider, you won’t risk getting sick from other people.
Considerations: You and your provider won’t be in the same room, so it may feel different than an office visit. Treating clients exclusively via phone consultations or emails may put therapists at a disadvantage because they cannot detect nonverbal cues, may not be able to accurately diagnose, may not always be aware of the resources available locally, and may not be able to intervene as effectively as necessary in emergency situations. Acute crises and severe psychological disturbances, such as schizophrenia, dissociation, bipolar or some types of personality disorders may not be effectively handled exclusively via phone, email or other web based communications.
1. We will not record visits with your provider. If people are close
to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.
2. Your provider will tell you if someone else from their office can hear or see you.
3. We use telehealth technology that is designed to protect your privacy.
4. If you use the Internet for telehealth, use a network that is private and secure.
5. There is a very small chance that someone could use technology to hear or see your telehealth visit.
6. I understand that while email may be used to communicate with my therapist/psychologist, confidentiality of emails cannot be guaranteed.
Rights: I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. The laws that protect the confidentiality of my medical information also apply to teletherapy.
This notice describes how medical information about you, the patient, may be used and disclosed and how you can get access to this information. Please review carefully.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
Uses and Disclosure of Protected Health Information
Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protect health information will be sued, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee new activities, training of medical students, licensing, and conducting or arranging for other business activates. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sigh-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose protected health information, as necessary to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect” Food and Drug Administration requirements: Legal Proceedings, Law Enforcement: Coroners, Funeral Directors, and Organ Notation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of Department of health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.
Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity Object unless required by law.
We may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protect health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction request and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complain. We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before April 14, 2003. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number