Effective date July 1, 2020.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
The protection of your health information is very important. We recognize that many of the things we discuss are sensitive, and because of this, it is important that you are aware of how this information is used and may be revealed. This document contains a description about how your protected health information is used and sometimes disclosed. As a provider of service covered under the federal “HIPAA” law we are required to give you this notice and to abide by its terms. (We reserve the right to change the terms of this notice, and if that happens we will provide you with an updated copy with the changes.)
In general, the communications between a patient and provider are confidential and protected by law and we can only release your protected health information with your permission, or under certain circumstances. This document and the other intake documents you received discuss those circumstances. When we make a disclosure, we will always try to limit the information that we reveal. In general, we will try to disclose only the amount necessary.
Uses and Disclosures:
We can disclose information for the purposes of treatment, payment, and health care operations. An example of a disclosure for treatment purposes is one where we discuss your treatment/evaluation with your general physician to coordinate our services. An example of a disclosure for payment is where we discuss your case with your health insurance carrier to determine if you are eligible for coverage. An example of a disclosure for health care operations is where we disclose information for the purposes of conducting quality assessment and quality improvement functions. We can also disclose information for the purposes of facilitating your care via our relationships with vendors and business associates that support our work with you, in which case the privacy of these disclosures are protected under the business associate agreements that we have in place with these vendors and associates. Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as administrative services, billing, auditing, accreditation, outcomes data collection, legal services, scheduling, etc. We may disclose your information to these business associates who assist us with our health care operations. In all cases, we require these associates to appropriately safeguard the privacy of your information. An example of a disclosure for the purposes of facilitating your care is the disclosure of information to an automated appointment scheduling service for the scheduling and coordination of your appointments, such as if one of our coaches contacts you via text messaging or via phone. Another example of a disclosure for the purposes of facilitating your care is the utilization of a third-party messaging service to transmit encrypted messages between you and your clinician.
We can also make disclosures without your consent under the following circumstances:
In some legal proceedings we may be required to disclose information about you without your consent. We will try to maintain the confidentiality of your protected health information, but if we receive a lawful order from a court or administrative authority, a valid subpoena, search warrant, or coroner’s inquest we may have to disclose information.
If we believe you or an identified patient pose a serious risk of harm to yourself or someone else, or if the welfare of a child is in jeopardy, we are required to take protective actions. This may mean that we have to contact a potential victim, the police, child and family services, government authorities whose job it is to protect the elderly or dependent adults, or other parties to minimize the risk of harm.
When we make disclosures for these purposes, we will disclose only the information necessary. Any additional disclosures will be made only with your written authorization and you can revoke that authorization at any time.
We are permitted to contact you to remind you about appointments, to discuss treatment alternatives, or other health-related services that may be of interest to you.
We are required by law to maintain the privacy of protected health information, to provide you with notice of our legal duties and privacy practices with respect to your protected health information, and to notify affected individuals following a breach of unsecured protected health information.
We are required to abide by the terms of the notice currently in effect.
We reserve the right to change the terms of this notice and to make the new notice provisions effective for all protected health information that we maintain. If we change the terms of this notice we will notify you via the email address you supplied to us upon registration, and/or the email address you have currently listed in your account profile.
Your Individual Rights:
You can request that we restrict the disclosure of information such as described above, but we are not required to agree to these restrictions. However, if we do agree to these restrictions we must abide by our agreement unless an emergency occurs. If we do have to disclose information in an emergency we will request the persons to whom we make the disclosure that the information remain as confidential as possible. Any agreement that we make to restrict these disclosures will be written down and signed; if either of us needs to terminate our agreement we will document our agreement in writing and give you a copy. You cannot limit the uses and disclosures that we are legally required or allowed to make.
If you wish to receive communications from us by alternative means (such as billing at a different address) you have the right to make reasonable requests. This is especially true if our usual means of communicating with you could endanger you or someone else. If you want to make such a request, please do so in writing and we will discuss how it would work and if it would be possible for us to agree to your request.
You have the right to inspect and copy your protected health information. You also have the right to amend your protected health information. If you want a copy of your protected health information, we can charge you a reasonable fee for providing you with these copies.
You have a right to receive an accounting of most of the disclosures of your protected health information that have occurred in the last six years.
You have a right to receive a paper copy of this notice.
If you have a complaint about how we have disclosed or failed to disclose your protected health information you can make a complaint to us, or to the U.S. Secretary of Health and Human Services at:
Office for Civil Rights Department of HHS
Jacob Javits Federal Building 26 Federal Plaza – Suite 3312
New York, NY 10278
Voice Phone (212) 264-3313
FAX (212) 264-3039
TDD (212) 264-2355
We will not retaliate against you for filing a complaint.
If you have any additional questions, you can contact us at our mailing address or via email:
175 Forest Ave. Palo Alto, CA 94301