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1200 Mt. Diablo Blvd. Suite 406 Walnut Creek, CA 94596 (925) 262-4136 Licensed Psychologist PSY19657 www.eastbaypsych.com |
| M A R Y L E E - L A U, P S Y. D. |
NOTICE OF PRIVACY PRACTICES
Effective 04/14/2003
This notice describes how personal and mental health information about you (your family or child) may be used
and how you can get access to this information. Please review it carefully.
My Legal Duty
I understand that your health/mental health information is personal and I am committed to protecting this
information. I am required by applicable federal and state law to maintain the privacy of your health information.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), also requires that I give you this Notice
about my legal duties, my privacy practices, and your rights concerning your health information. I must follow the
privacy practices that are described in this Notice while it is in effect.
Individually identifiable information about your past, present, or future health/mental health or condition, the
provision of health/mental health care to you, or payment for the health/mental health care is considered
“Protected Health Information (PHI).” Whenever possible, the PHI contained in your record remains private. In
some circumstances, it is necessary for me to share some of the PHI contained in your record (or your child’s
record). In all but certain specified circumstances, I will share only the minimum necessary PHI to accomplish
the intended purpose of the use or disclosure.
I reserve the right to change this notice and to make changes in my privacy practices. Any changes will be
effective for all PHI that I maintain, including health/mental health information created or received before I made
the changes. I will post a copy of the current notice in my reception area or office. You may also request a
current copy of this notice from me.
How I May Use and Disclose Health/Mental Health Information About You:
The following categories describe different ways that I use and disclose your PHI. For each category, I explain
what I mean, and offer an example. In some instances a written authorization signed by you is required in order
for me to use or disclose your PHI; in others it is not. I have tried to identify which instances do not require your
signed authorization and which do.
Uses and Disclosures of PHI for Which No Signed Authorization is Required:
For Treatment: I may use/disclose your (or your child’s) PHI to provide you with mental health treatment or
services. For example, I can disclose your PHI to physicians, psychiatrists, and other licensed health care
providers who provide you with health care services or are involved in your care. If a psychiatrist is treating you, I
can disclose your PHI to your psychiatrist in order to coordinate your care.
For Payment: I may use/disclose your (or your child’s) PHI in order to bill and collect payment (from you, your
insurance company, or another third party) for services provided by me. For example, I may send your PHI to
your insurance coverage to get paid for the services we provided to you or to determine eligibility for coverage.
For Health Care Operations: I may use/disclose your (or your child’s) PHI to your health care service plan or
insurance company for purposes of administering the plan, such as case management and care coordination.
Appointment Reminders or Changes in Appointments: I may use/disclose your (or your child’s) PHI to contact
you as a reminder that you have an appointment. I may also contact you to notify you of a change in your
appointment. For example, if I am ill, I may have someone in my office contact you to notify you that the
appointment is cancelled. If you do not wish me to contact you for appointment reminders or changes in
appointment times, please provide me with alternative instructions (in writing).
When disclosure is required by state, federal or local law; judicial or administrative proceedings; or law
enforcement: I may use/disclose your (or your child’s) PHI when a law requires that I report information about
suspected child, elder or dependent adult abuse or neglect; or in response to a court order. I must also
disclose information to authorities that monitor compliance with these privacy requirements.
To Avoid Harm: I may use or disclose limited PHI about you when necessary to prevent or lessen a serious
threat to your health or safety, or the health and safety of the public or another person. If I reasonably believe you
pose a serious threat of harm to yourself, I may contact family members or others who can help protect you. If
you communicate a serious threat of bodily harm to another, I will be required to notify law enforcement and the
potential victim.
Law Enforcement Officials: I may disclose your (or your child’s) PHI to the police or other law enforcement
officials as required or permitted by law or in compliance with a court order or grand jury or administrative
subpoena.
For Health Oversight Activities: I may disclose PHI to a health oversight agency for activities authorized by law.
For example, I may have to provide information to assist the government when it conducts an investigation or
inspection of a health care provider or organization.
Specialized Government Functions: I may disclose you (or your child’s) PHI to units of the government with
special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
Disclosure to Relatives, Close Friends and Other Caregivers: I may use or disclose your PHI to a family
member, other relative, a close personal friend or any other person that you indicate is involved in your care or
the payment of your care unless you object in whole or in part. If you are not present, or the opportunity to agree
or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency
circumstance, I may exercise my professional judgment to determine whether a disclosure is in your best
interests. If I disclose PHI to a family member, other relative or a close personal friend, I would disclose only
information that I believe is directly relevant to the person’s involvement with your health care or payment related
to your health care.
Workers’ Compensation: I may disclose your PHI as authorized by and to the extent necessary to comply with
California law relating to workers’ compensation or other similar programs.
As required by law: I may use and disclose your (or your child’s) PHI when required to do so by any other law not
already referred to in the preceding categories.
Uses and Disclosures of PHI for Which a Signed Authorization is Required: For uses and disclosures of PHI
beyond the areas noted above, I must obtain your written authorization. Authorizations can be revoked at any
time in writing to stop future uses/disclosures (except to the extent that I have already acted upon your
authorization).
Your Rights Regarding Your (or Your Child’s) PHI:
You have the following rights regarding PHI I maintain about you (or your child):
Right to Inspect and Copy: You have the right to inspect and copy your (or your child’s) health/mental health
information upon your written request. However, some mental health information may not be accessed for
treatment reasons and for other reasons pertaining to California or federal law. I will respond to your written
request to inspect records. A charge for copying, mailing and related expenses will apply.
Right to Request Restrictions: You have the right to ask that I limit how I use or disclose your PHI. I will consider
your request, but I am not legally required to agree to the request. If I do agree to your request, I will put it into
writing and comply with it except in emergency situations. I cannot agree to limit uses and/or disclosures that
are required by law.
Right to Amend: If you believe that there is a mistake or missing information in my record of your health/mental
health information, you may request, in writing, that I correct or add to the record. I will respond to your request
within 60 days of receiving it. I may deny your request for an amendment if it is not in writing or does not include
a reason to support the request. In addition, I may deny your request to amend information that: was not created
by me, not part of my records, not part of the information that you would be permitted to inspect and copy or is
accurate and complete.
Right to an Accounting of Disclosures: You have a right to get a list of when, to whom, for what purpose, and
what content of your (your child’s) PHI has been disclosed. This applies to disclosures other than those made
for purposes of treatment payment, or health care operations. Your request must be in writing and state a time
period (which may not be longer than six (6) years and may not include dates before April 14, 2003). I will
respond to your request within sixty (60) days of receiving it. The first list you request within a 12 month period
will be free. There may be a charge for more frequent lists. In such a case, I will notify you of the cost involved
and you may choose to change or withdraw your request before any costs are incurred.
Right to Request Confidential Communications: You have the right to request that I communicate with you about
health/mental health matters in a certain way or at a certain location. For example, you can ask that I only contact
you at work. To request confidential communications, you must make your request in writing. Please specify
how or where you wish to be contacted. I will accommodate all reasonable requests.
Right to a Paper Copy of this Notice: You have a right to a paper copy of this notice. You may ask me to give you
a copy at any time.
Complaints:
If you think that your privacy rights have been violated you may contact me at (925) 262-4136 or you may file a
complaint to the Secretary of the Department of Health and Human Services at 200 Independence Ave. S.W.,
Washington, D.C. 20201. You will not be penalized for filing a complaint.
Effective 04/14/2003
This notice describes how personal and mental health information about you (your family or child) may be used
and how you can get access to this information. Please review it carefully.
My Legal Duty
I understand that your health/mental health information is personal and I am committed to protecting this
information. I am required by applicable federal and state law to maintain the privacy of your health information.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), also requires that I give you this Notice
about my legal duties, my privacy practices, and your rights concerning your health information. I must follow the
privacy practices that are described in this Notice while it is in effect.
Individually identifiable information about your past, present, or future health/mental health or condition, the
provision of health/mental health care to you, or payment for the health/mental health care is considered
“Protected Health Information (PHI).” Whenever possible, the PHI contained in your record remains private. In
some circumstances, it is necessary for me to share some of the PHI contained in your record (or your child’s
record). In all but certain specified circumstances, I will share only the minimum necessary PHI to accomplish
the intended purpose of the use or disclosure.
I reserve the right to change this notice and to make changes in my privacy practices. Any changes will be
effective for all PHI that I maintain, including health/mental health information created or received before I made
the changes. I will post a copy of the current notice in my reception area or office. You may also request a
current copy of this notice from me.
How I May Use and Disclose Health/Mental Health Information About You:
The following categories describe different ways that I use and disclose your PHI. For each category, I explain
what I mean, and offer an example. In some instances a written authorization signed by you is required in order
for me to use or disclose your PHI; in others it is not. I have tried to identify which instances do not require your
signed authorization and which do.
Uses and Disclosures of PHI for Which No Signed Authorization is Required:
For Treatment: I may use/disclose your (or your child’s) PHI to provide you with mental health treatment or
services. For example, I can disclose your PHI to physicians, psychiatrists, and other licensed health care
providers who provide you with health care services or are involved in your care. If a psychiatrist is treating you, I
can disclose your PHI to your psychiatrist in order to coordinate your care.
For Payment: I may use/disclose your (or your child’s) PHI in order to bill and collect payment (from you, your
insurance company, or another third party) for services provided by me. For example, I may send your PHI to
your insurance coverage to get paid for the services we provided to you or to determine eligibility for coverage.
For Health Care Operations: I may use/disclose your (or your child’s) PHI to your health care service plan or
insurance company for purposes of administering the plan, such as case management and care coordination.
Appointment Reminders or Changes in Appointments: I may use/disclose your (or your child’s) PHI to contact
you as a reminder that you have an appointment. I may also contact you to notify you of a change in your
appointment. For example, if I am ill, I may have someone in my office contact you to notify you that the
appointment is cancelled. If you do not wish me to contact you for appointment reminders or changes in
appointment times, please provide me with alternative instructions (in writing).
When disclosure is required by state, federal or local law; judicial or administrative proceedings; or law
enforcement: I may use/disclose your (or your child’s) PHI when a law requires that I report information about
suspected child, elder or dependent adult abuse or neglect; or in response to a court order. I must also
disclose information to authorities that monitor compliance with these privacy requirements.
To Avoid Harm: I may use or disclose limited PHI about you when necessary to prevent or lessen a serious
threat to your health or safety, or the health and safety of the public or another person. If I reasonably believe you
pose a serious threat of harm to yourself, I may contact family members or others who can help protect you. If
you communicate a serious threat of bodily harm to another, I will be required to notify law enforcement and the
potential victim.
Law Enforcement Officials: I may disclose your (or your child’s) PHI to the police or other law enforcement
officials as required or permitted by law or in compliance with a court order or grand jury or administrative
subpoena.
For Health Oversight Activities: I may disclose PHI to a health oversight agency for activities authorized by law.
For example, I may have to provide information to assist the government when it conducts an investigation or
inspection of a health care provider or organization.
Specialized Government Functions: I may disclose you (or your child’s) PHI to units of the government with
special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
Disclosure to Relatives, Close Friends and Other Caregivers: I may use or disclose your PHI to a family
member, other relative, a close personal friend or any other person that you indicate is involved in your care or
the payment of your care unless you object in whole or in part. If you are not present, or the opportunity to agree
or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency
circumstance, I may exercise my professional judgment to determine whether a disclosure is in your best
interests. If I disclose PHI to a family member, other relative or a close personal friend, I would disclose only
information that I believe is directly relevant to the person’s involvement with your health care or payment related
to your health care.
Workers’ Compensation: I may disclose your PHI as authorized by and to the extent necessary to comply with
California law relating to workers’ compensation or other similar programs.
As required by law: I may use and disclose your (or your child’s) PHI when required to do so by any other law not
already referred to in the preceding categories.
Uses and Disclosures of PHI for Which a Signed Authorization is Required: For uses and disclosures of PHI
beyond the areas noted above, I must obtain your written authorization. Authorizations can be revoked at any
time in writing to stop future uses/disclosures (except to the extent that I have already acted upon your
authorization).
Your Rights Regarding Your (or Your Child’s) PHI:
You have the following rights regarding PHI I maintain about you (or your child):
Right to Inspect and Copy: You have the right to inspect and copy your (or your child’s) health/mental health
information upon your written request. However, some mental health information may not be accessed for
treatment reasons and for other reasons pertaining to California or federal law. I will respond to your written
request to inspect records. A charge for copying, mailing and related expenses will apply.
Right to Request Restrictions: You have the right to ask that I limit how I use or disclose your PHI. I will consider
your request, but I am not legally required to agree to the request. If I do agree to your request, I will put it into
writing and comply with it except in emergency situations. I cannot agree to limit uses and/or disclosures that
are required by law.
Right to Amend: If you believe that there is a mistake or missing information in my record of your health/mental
health information, you may request, in writing, that I correct or add to the record. I will respond to your request
within 60 days of receiving it. I may deny your request for an amendment if it is not in writing or does not include
a reason to support the request. In addition, I may deny your request to amend information that: was not created
by me, not part of my records, not part of the information that you would be permitted to inspect and copy or is
accurate and complete.
Right to an Accounting of Disclosures: You have a right to get a list of when, to whom, for what purpose, and
what content of your (your child’s) PHI has been disclosed. This applies to disclosures other than those made
for purposes of treatment payment, or health care operations. Your request must be in writing and state a time
period (which may not be longer than six (6) years and may not include dates before April 14, 2003). I will
respond to your request within sixty (60) days of receiving it. The first list you request within a 12 month period
will be free. There may be a charge for more frequent lists. In such a case, I will notify you of the cost involved
and you may choose to change or withdraw your request before any costs are incurred.
Right to Request Confidential Communications: You have the right to request that I communicate with you about
health/mental health matters in a certain way or at a certain location. For example, you can ask that I only contact
you at work. To request confidential communications, you must make your request in writing. Please specify
how or where you wish to be contacted. I will accommodate all reasonable requests.
Right to a Paper Copy of this Notice: You have a right to a paper copy of this notice. You may ask me to give you
a copy at any time.
Complaints:
If you think that your privacy rights have been violated you may contact me at (925) 262-4136 or you may file a
complaint to the Secretary of the Department of Health and Human Services at 200 Independence Ave. S.W.,
Washington, D.C. 20201. You will not be penalized for filing a complaint.