HIPAA
Confidentiality
Policy
This website subscribes to the
guidelines of confidentiality
adopted by American Medical Association
and the American Psychological
Association known as the Health
Insurance Portability and Accountability
Act (HIPAA). This is federal
law that provides new privacy
protections and new patient rights
with regards to the use and disclosure
of Protected Health Information
(PHI) used for the purpose of
treatment, payment and health
care operations.
Even though this website is designed
only for information and education
purposes and not for offering
treatment, diagnosis or advice,
any personal information disclosed
by a visitor will be held as
confidential and will not be
disclosed to anyone without the
express written permission of
the visitor. Any personal information
given by electronic means will
be saved in electronic form for
180 days and then discarded.
Efforts will be made to encrypt
or code all electronic information
to further secure and make safe
visitor information.
Visitors who provide questionnaire
or other information are not
patients of Pacifica Pain Management
Services, Inc.
CALIFORNIA
NOTICE FORM
Notice
of Policies and Practices to
Protect the Privacy of Your Health
Information
I.
Disclosures for Treatment, Payment,
and Health Care Operations
I may use or disclose your confidential
PHI for certain treatment, payment,
and health care operations purposes
without your authorization. In
certain circumstances I can only
do so when the person or business
requesting your PHI gives me
a written request that includes
certain promises regarding protecting
the confidentiality of your PHI.
To help clarify these terms,
her are some definitions:
- "PHI" refers to information
in your health record
that could identify you.
- "Treatment and Payment
Operations"
Treatment is when
I provide or another healthcare
provider diagnoses or treats
you. An example of treatment
would be when I consult with
another health care provider,
such as your family physician
regarding your treatment.
Payment is when I obtain
reimbursement for your healthcare.
Examples of payment are when
I disclose your PHI to your
health insurer to obtain
reimbursement for your healthcare
or to determine eligibility
or coverage.
Health Care Operations is
when I disclose your PHI
to your health care service
plan (insurer), or to your
other providers contracting
with your plan, for administering
the plan, such as case management
and care coordination.
- "Use" applies only to
activities within my
clinic such as sharing,
employing, applying,
utilizing, examining,
and analyzing information
that identifies you.
- "Disclosure" applies
to activities outside
of my clinic, such as
releasing, transferring,
or providing access to
information about you
to other parties.
- "Authorization" means
written permission for
specific uses or disclosures.
II.
Uses and Disclosures Requiring
Authorization
I 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 I am asked for information
for purposes outside of treatment
and payment operations, I will
obtain authorization from you
before releasing this information.
I will also need to obtain an
authorization before releasing
your psychotherapy notes. "Psychotherapy
Notes" are notes I have made
about our conversation during
a private, group, joint, or family
counseling session, which I have
dept 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 authorization (PHI or psychotherapy
notes) at any time; however,
the revocation or modification
is not effective until I receive
it.
III.
Uses and Disclosures with Neither
Consent nor Authorization
I may use or disclose PHI without
your consent or authorization
in the following circumstances:
- Child
Abuse: Whenever
I, in my professional
capacity, have knowledge
of or observe a child
I know or reasonably
suspect, has been
the victim of child
abuse or neglect,
I must immediately
report such to a
police department
or sheriffs department,
county probation
department, or county
welfare department.
Also, if I have knowledge
of or reasonably
suspect mental suffering
has inflicted upon
a child or that his
or her emotional
well-being is endangered
in any other way
I may report such
to the above agencies.
- Adult
and domestic Abuse: If
I, in my professional
capacity, have observed
or have 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 I am
told b an elder or
dependent adult that
he or she has experienced
these or if I reasonably
suspect such, I must
report the known
or suspected abused
immediately to the
local ombudsman or
the local law enforcement
agency.
I do not have to report
such an incident if :
- I have been told
by an elder or
dependent adult
that he or she
has experienced
behavior constituting
physical abuse,
abandonment,
abduction, isolation,
financial abuse
or neglect;
- I am not aware
of any independent
evidence that
corroborates
the statement
that the abuse
has occurred.
- the elder or
dependent adult
ahs bee diagnosed
with a mental
illness or dementia,
or is the subject
of a court-ordered
conservatorship
because of a
mental illness
or dementia;
and
- in the exercise
of clinical judgment,
I reasonably
believe that
the abuse did
not occur.
- Health
Oversight: If
a complaint is filed
against me with the
California Medical
or Psychological
Board, the Board
has the authority
to subpoena confidential
medical and mental
health information
from me 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 I have
provided you, I must
not release your
information without
1) your written authorization
or the authorization
of your attorney
or professional representative;
2) a court order;
or 3) a subpoena
duces tecum ( a subpoena
to produce records)
where the party seeking
your records provides
me with a showing
that you or your
attorney have been
served wit a copy
of the subpoena,
affidavit and the
appropriate notice
and you have not
notified me 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.
I will inform you
in advance if this
is the case.
- Serious
Threat to Health
or Safety: If
you communicate to
me a serious threat
of physical violence
against an identifiably
victim, I must make
reasonable efforts
to communicate that
information to the
potential victim
and the police. If
I have reasonable
cause t believe that
you are in such a
condition, a to be
dangerous t yourself
or others, I may
release relevant
information as necessary
to prevent the threatened
danger.
- Worker's
Compensation: If
you file a worker's
compensation claim
I must furnish a
report to your employer,
incorporating my
findings about your
injury and treatment,
within five working
days from the date
of your initial examination
and at subsequent
intervals as may
be required by the
administrative director
of the Worker's Compensation
Commission in order
to determine your
eligibility for worker's
compensation benefits.
IV.
Patient's Rights and Psychologist's
Duties
Patients's Rights:
- Right
to request restrictions -
You have the right
to request restrictions
on certain uses and
disclosures of PHI
about you. However,
I am 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
seeing me. Upon request,
I will send your
bills to another
address).
- Right
to inspect and copy -
You have the right
to obtain a copy
(or both) of PHI
in my mental and
medical health and
billing records used
to make decisions
about you for as
long as the PHI is
maintained in the
record. I may deny
your access to PHI
under certain circumstances,
but in some cases
you may have this
decision reviewed.
On your request,
I 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. I
may deny your request.
On your request,
I 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
. On your request,
I will discuss with
you the details of
the accounting process.
- Right
to a paper copy -
You have the right
to obtain paper copy
of the notice from
me upon request,
even if you have
agreed to receive
the notice electronically.
Psychologist's Duties:
I am required by law to maintain
the privacy of PHI and to provide
you with a notice of my legal
duties and privacy practices
with respect to PHI. I reserve
the right to change the privacy
policies and practices described
in this notice. Unless I notify
of such changes, however, I am
required to abide by the terms
currently in effect. If I revise
my policies and procedures I
will notify you by U.S. mail.
V.
Questions and Complaints
If you have questions about this
notice, disagree with a decision
we make about access to your
records, or have other concerns
about your privacy rights, you
may contact Pacifica Pain Management
Services, Inc. at (707) 963-1493
or electronically at Pacificapain.com.
If you believe that your privacy
rights have been violated and
wish to file a complaint with
my office, you may send your
written complaint to Gary Mills,
Ph.D., 1700 Soscol Suite 25,
Napa, CA 94559.
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. I will not
retaliate against you for exercising
your right to file a complaint.
VI.
Effective Date, Restrictions,
and Changes to Privacy Policy
This notice will go into effect
on April 14, 2003.
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