HIPAA Notice of Privacy Practices

Effective Date: [Effective Date]

This notice is provided by Peaches Mindcare — Amber Faille, LCSW (1000 Lincoln Rd, Ste H, PMB 38, Yuba City, CA 95991, phone (619) 535-8567, email afaille@moonstonerecovery.com), referred to as “I,” “me,” or “this practice.” Peaches Mindcare is a fictitious business name (DBA) of Moonstone Recovery, Inc.

My Commitment to Your Privacy

I am required by law to maintain the privacy of your protected health information (PHI), to give you this notice of my legal duties and privacy practices, and to abide by the terms of the notice currently in effect. California law, including the Confidentiality of Medical Information Act (CMIA), provides protections that are in some cases stronger than federal law; where California law is more protective of your privacy, I follow California law.

How I May Use and Disclose Your Health Information

Uses and Disclosures Not Requiring Your Authorization

• Treatment. I may use your health information to provide, coordinate, or manage your care, and — with appropriate safeguards or your authorization where required — to consult or coordinate with other providers involved in your care.
• Payment. I may use and disclose your information to obtain payment for services, for example when preparing a superbill at your request for you to submit to your insurance.
• Health Care Operations. I may use your information for activities necessary to run the practice, such as quality review, professional consultation (with identifying details removed whenever possible), and business planning.

Psychotherapy Notes

Psychotherapy notes (my personal process notes kept separate from your clinical record) receive special protection. Most uses and disclosures of psychotherapy notes require your written authorization, including for treatment by others, payment, and operations purposes.

Uses and Disclosures Requiring Your Written Authorization

I will not use or disclose your health information for the following purposes without your written authorization: marketing; sale of your information; most disclosures of psychotherapy notes; and any purpose not described in this notice. You may revoke an authorization at any time in writing, except to the extent I have already acted in reliance on it.

Other Uses and Disclosures Permitted or Required by Law

• When required by law — including mandated reporting of suspected child abuse or neglect and elder or dependent adult abuse.
• To avert a serious threat to your health or safety or the safety of others, including the duty to protect identifiable potential victims under California law.
• Public health and health oversight activities — to public health authorities and to agencies such as the Board of Behavioral Sciences in connection with audits, investigations, or licensure actions.
• Judicial and administrative proceedings — in response to a valid court order, or in some cases a subpoena where legal requirements are met.
• Law enforcement — in limited circumstances defined by law.
• Workers’ compensation — as authorized by workers’ compensation laws.
• Coroners and medical examiners — as necessary to carry out their duties.

Other uses and disclosures not described in this notice will be made only with your written authorization.

Your Rights Regarding Your Health Information

• Right to inspect and copy. You may request to inspect or receive a copy of your health record. California law generally requires me to permit inspection within 5 business days and to provide copies within 15 days of your written request. Limited exceptions apply; a reasonable, cost-based fee may be charged for copies.
• Right to amend. If you believe information in your record is incorrect or incomplete, you may request an amendment in writing. I may deny the request in certain cases, and you have the right to submit a statement of disagreement, which will be kept with your record.
• Right to an accounting of disclosures. You may request a list of certain disclosures I have made of your information, other than those for treatment, payment, operations, or made to you or with your authorization.
• Right to request restrictions. You may request restrictions on how I use or disclose your information. I am not required to agree to all requests, but I must agree to restrict disclosures to a health plan for services you have paid for in full out of pocket.
• Right to confidential communications. You may request that I contact you in a specific way (for example, only at a certain phone number or address). I will accommodate all reasonable requests.
• Right to a paper copy. You may request a paper copy of this notice at any time, even if you have agreed to receive it electronically.
• Right to breach notification. You have the right to be notified if a breach of your unsecured health information occurs.

My Duties

I am required by law to maintain the privacy of your PHI, provide you this notice, notify you following a breach of unsecured PHI, and follow the terms of the notice currently in effect.

Changes to This Notice

I reserve the right to change this notice and to make the revised notice effective for information I already have as well as information I receive in the future. The current notice, with its effective date, will always be posted on this page and available in the office.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with me directly at the contact information above, or with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue S.W., Washington, D.C. 20201, by calling 1-877-696-6775, or online at www.hhs.gov/ocr/complaints. You will not be penalized or retaliated against in any way for filing a complaint.

Acknowledgment of Receipt

By signing below, I acknowledge that I have received and had the opportunity to review this Notice of Privacy Practices. (Your signature acknowledges receipt only; it is not a consent or authorization.)

Parent / Legal Guardian (if acknowledging on behalf of a minor):