• "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.

• 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 :
  1. 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;
  2. I am not aware of any independent evidence that corroborates the statement that the abuse has occurred.
  3. 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
  4. 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.

• 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.