HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact Michelle Garcia, Psy.D.

Who Will Follow This Notice

This notice describes Michelle Garcia, Psy.D. & Associates practices and that of:

• Any health care professional authorized to enter information into your Michelle Garcia, Psy.D. & Associates chart.
• All employees, staff and other Michelle Garcia, Psy.D. & Associates personnel.

Our Pledge Regarding Mental Health Information

We understand that mental health information about you and your health is personal. We are committed to protecting mental health information about you. We create a record of the care and services you receive at Michelle Garcia, Psy.D. & Associates. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Michelle Garcia, Psy.D. & Associates.

This notice will tell you about the ways in which we may use and disclose mental health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of mental health information.

We are required by law to:

• make sure that mental health information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to mental health information about you; and
• follow the terms of the notice that is currently in effect.

How We May Use and Disclose Mental Health Information About You

The following categories describe different ways that we use and disclose mental health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment. We may use mental health information about you to provide you with mental health treatment or services. We may disclose mental health information about you to other Michelle Garcia, Psy.D. & Associates personnel, who are involved in taking care of you within Michelle Garcia, Psy.D. & Associates. We also may disclose mental health information about you to people outside the Michelle Garcia, Psy.D. & Associates who may be involved in your mental health care, such as case managers, legal advocates or guardians, family members, or new treating providers after you no longer receive services from Michelle Garcia, Psy.D. & Associates.

For Payment. We may use and disclose mental health information about you so that the treatment and services you receive within Michelle Garcia, Psy.D. & Associates may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about treatment you received within Michelle Garcia, Psy.D. & Associates so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. We may use and disclose mental health information about you for Michelle Garcia, Psy.D. & Associates operations. These uses and disclosures are necessary to run Michelle Garcia, Psy.D. & Associates and make sure that all of our patients receive quality care. For example, we may use mental health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine mental health information about many patients to decide what additional services Michelle Garcia, Psy.D. & Associates should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to other Michelle Garcia, Psy.D. & Associates personnel for review and learning purposes. We may also combine the mental health information we have with mental health information from other Michelle Garcia, Psy.D. & Associates clinical staff to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of mental health information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders. We may use and disclose mental health information to contact you as a reminder that you have an appointment for treatment or mental health care with Michelle Garcia, Psy.D. & Associates.

Treatment Alternatives. We may use and disclose mental health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose mental health information to tell you about health-related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. We may release mental health information about you to a friend, family member, legal advocate, legal guardian, or case manager who is involved in your mental health care. We may also give information to someone who helps pay for your care. We may also tell your family, friends, legal advocate, legal guardian, or case manager your condition and that you are receiving services from Michelle Garcia, Psy.D. & Associates.

Research. Under certain circumstances, we may use and disclose mental health information about you for research purposes. For example, a research project may involve comparing the behavioral status and quality of life of all patients who received one type of service with those who received another, for the same circumstances. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of mental health information, trying to balance the research needs with patients' need for privacy of their mental health information. Before we use or disclose mental health information for research, the project will have been approved through this research approval process, but we may, however, disclose mental health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific mental health needs, so long as the mental health information they review does not leave Michelle Garcia, Psy.D. & Associates. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care with Michelle Garcia, Psy.D. & Associates.

As Required By Law. We will disclose mental health information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose mental health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Special Situations

Military and Veterans. If you are a member of the armed forces, we may release mental health information about you as required by military command authorities. We may also release mental health information about foreign military personnel to the appropriate foreign military authority.

Workers' Compensation. We may release mental health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose mental health information about you for public health activities. These activities generally include the following:

• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report child abuse or neglect;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose mental health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose mental health information about you in response to a court or administrative order. We may also disclose mental health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release mental health information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct within Michelle Garcia, Psy.D. & Associates and
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

National Security and Intelligence Activities. We may release mental health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose mental health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release mental health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Your Rights Regarding Mental Health Information About You

You have the following rights regarding mental health information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy mental health information that may be used to make decisions about your care. Usually, this includes mental health and billing records, but does not include psychotherapy notes.

To inspect and copy mental health information that may be used to make decisions about you, you must submit your request in writing to Michelle Garcia, Psy.D. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to mental health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Michelle Garcia, Psy.D. & Associates will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that mental health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Michelle Garcia, Psy.D. & Associates.

To request an amendment, your request must be made in writing and submitted to Michelle Garcia, Psy.D. In addition, you must provide a reason that supports your request. We 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, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the mental health information kept by or for Michelle Garcia, Psy.D. & Associates;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of mental health information about you.

To request this list or accounting of disclosures, you must submit your request in writing to Michelle Garcia, Psy.D. Your request must state a time period which may not be longer than six years and may not include dates before March 12, 2008. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the mental health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the mental health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member, case manager, or friend. For example, you could ask that we not use or disclose information about a treatment you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to Michelle Garcia, Psy.D. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications. You have the right to request that we communicate with you about mental health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Michelle Garcia, Psy.D. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice contact Michelle Garcia, Psy.D.

Changes to This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for mental health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in Michelle Garcia, Psy.D. & Associates. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you receive services from Michelle Garcia, Psy.D. & Associates for treatment or health care services, you are welcome to ask for a copy of the current notice in effect.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Michelle Garcia, Psy.D. & Associates or with the Secretary of the Department of Health and Human Services. To file a complaint with Michelle Garcia, Psy.D., contact Michelle Garcia, Psy.D., President, at 713-397-3104. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

Other Uses of Mental Health Information

Other uses and disclosures of mental health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose mental health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose mental health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.