Book NowHIPAA Notice of Privacy Practices
This document contains important information about federal law, the Health Information Portability and
Accountability Act (HIPAA), which provides privacy protections and patient rights about the use and
disclosure of your Protected Health Information (PHI) used for treatment, payment, and health care
operations.
HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for the use and
disclosure of PHI for treatment, payment, and healthcare operations. The Notice explains HIPAA and its
application to your PHI in greater detail.
In addition, certain records related to Substance Use Disorder (SUD) diagnosis, treatment, or referral may
be protected under federal regulation 42 C.F.R. Part 2. These records receive additional confidentiality
protections beyond standard HIPAA protections.
The law requires that we make a good faith effort to obtain your written acknowledgment that you have received this
Notice. Your signature does not constitute agreement to any specific use or disclosure of your PHI.
Use and Disclosure of Protected Health Information:
For Treatment – We use and disclose your health information internally in the course of your
treatment. If we wish to provide information outside of our practice for your treatment by another
healthcare provider, we will have you sign an authorization for the release of information. Furthermore,
authorization is required for most uses and disclosures of psychotherapy notes.
If we receive or maintain Substance Use Disorder (SUD) treatment records protected under 42 C.F.R. Part 2,
those records may be used or disclosed for treatment purposes in accordance with federal law. Certain
disclosures may require your specific written consent.
For Payment – We may use and disclose your health information to obtain payment for services
provided to you.
If you pay for a service or healthcare item out-of-pocket in full, you may request that we not disclose that
information to your health insurer for payment or healthcare operations purposes. We will agree to such
request unless disclosure is otherwise required by law.
For Operations – We may use and disclose your health information as part of our internal operations.
For example, this may include review of records to assure quality of care, staff training, licensing,
accreditation, auditing, and business management activities.
We may also use your information to tell you about services, educational activities, and programs that we
feel might be of interest to you.
For HIV Disclosure– Under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule,
public health authorities are authorized to collect and receive private health information “for the purpose
of preventing or controlling disease” and in the “conduct of public health surveillance…” without patient or
provider consent or authorization other than state or local public health law. This clause authorizes
providers to report HIV/AIDS cases to the HIV Epidemiology Program without obtaining patient consent
and it authorizes health department personnel to review medical records and any other source of
information needed to report the case.
Any other disclosure of HIV-related information must be made on the “HIPAA- Compliant Authorization for
Release of Medical Information and Confidential HIV-Related Information”. Disclosure must comply with applicable
federal and state law, which prohibits any further disclosure of HIV-related private health information without
the specific written consent of the person to whom it pertains, or as otherwise permitted by law.
Special Protections for Substance Use Disorder (SUD) Treatment Records:
Certain Substance Use Disorder treatment records may be protected under 42 C.F.R. Part 2 –
If we receive or maintain such records:
- These records are confidential and may not be used or disclosed without your written consent unless
otherwise permitted by federal law. - You have the right to revoke your written consent at any time, except to the extent that action has
already been taken in reliance on that consent. - SUD treatment records disclosed with your consent may be additionally disclosed for treatment,
payment, and healthcare operations as permitted by applicable federal law. - Federal law generally prohibits the use or disclosure of SUD treatment records in criminal investigations
or prosecutions against you without a specific court order. - Unauthorized disclosures of these records may result in civil and criminal penalties.
- Complaints regarding SUD record violations may also be filed with HHS.
Client Rights:
Right to Treatment – You have the right to ethical treatment without discrimination regarding race,
ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected
category.
Right to Confidentiality – You have the right to have your healthcare information protected in
accordance with federal and state law.
Right to Request Restrictions – You have the right to request restrictions on certain uses and
disclosures of protected health information about you. However, we are not required to agree to all
requested restrictions except where required by law.
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.
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records
must be requested in writing. Furthermore, there may be a copying fee (see Practice Fee Schedule for
cost). Please make your request well in advance and allow 2 weeks to receive the copies. If we deny
access, you have the right to request a review of that denial.
Right to Amend – If you believe the information in your records is incorrect and/or missing important
information, you can ask us to make certain changes, also known as amending, to your health
information. You have to make this request in writing. You must tell us the reasons you want to make
these changes, and we will decide if it is and if we refuse to do so, we will tell you why within 60 days.
Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your
email. If you completed this paperwork in the office at your first session, a copy will be provided to you
per your request or at any time.
Right to an Accounting – You generally have the right to receive an accounting of certain disclosures
of PHI made outside of treatment, payment, and healthcare operations. At your request, we will discuss
with you the details of the accounting process.
Right to Choose Someone to Act for You – If someone is your legal guardian or personal
representative, that person can exercise your rights and make choices about your health information; we
will make sure the person has this authority and can act for you before we take any action.
Right to Terminate – You have the right to terminate services with us at any time without any legal or
financial obligations other than those already accrued. We ask that you discuss your decision with us in
session before terminating, or at least contact must be made by phone, letting us know you are
terminating services.
Right to Release Information with Written Consent – With your written consent, any part of your
record can be released to any person or agency you designate.
Right to File a Complaint – If you believe your privacy rights have been violated.
You may file a complaint with our Privacy Officer at:
Attn: Privacy Officer
PO Box 31001-3020
Pasadena, CA 91110-3020
833-478-2633
You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.
Clinician Duties:
We are required by law to maintain the privacy of PHI and to notify you following a breach of unsecured
PHI. We will provide you with a notice of our legal duties and privacy practices concerning PHI. We reserve
the right to change the privacy policies and practices described in this notice. Unless we notify you of such
changes, however, we are required to abide by the terms currently in effect. If we revise our policies and
procedures, we will provide you with an updated Notice.
Updated 04/1/2026