Terms of Use/Privacy Policy

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

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written authorization. To help clarify these terms, here are some definitions:

•  “PHI” refers to information in your health record that could identify you.
•  “Treatment, Payment, and Health Care Operations”

– Treatment is when we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist.

– Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

– Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

• “Use” applies only to activities within our practice group, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of our practice group, such as releasing, transferring, or providing access to information about you to other parties.
• “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.

II. Other Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes a counselor has made about your therapy during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures without Authorization

We may release PHI to a third-party payor or peer review organization with the prior written consent of you or your legal representative.

We may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse – If a therapist reasonably believes a child, whom s/he is treating, has been abused, s/he must report this belief to the appropriate authorities as required by law.
• Adult and Domestic Abuse – If a counselor suspects that a dependent adult has been abused, s/he must report this suspicion to the appropriate authorities as required by law.
• Health Oversight Activities – If we receive a subpoena from the Iowa Board of Psychology Examiners for protected health information regarding you, we must comply with that subpoena and disclose that information to the Board.
• Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made about the professional services we provided you or the records thereof, such information is privileged under state law, and we will not release information without your written consent or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
• Serious Threat to Health or Safety – If we believe you present a clear, imminent risk to another person, we may disclose information necessary to seek hospitalization or otherwise protect that individual. If we believe there is a clear and imminent risk that you will harm yourself, we may disclose information necessary to seek hospitalization for you or to alert family members or others who have the ability to protect you.
• Worker’s Compensation – we may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

IV. Patient’s Rights and Psychologist’s Duties

Patient’s Rights:

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. 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. On your request, I will send your bills to another address.)
• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental 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. 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 a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
  Therapist’s Duties:
• We are 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.
• We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we am required to abide by the terms currently in effect.
• If we revise our policies and procedures, we will offer you a revised Notice of Privacy Practices form as long as you are an active client.

V. Questions and Complaints

If you have questions about this notice, or disagree with a decision your therapist has made about access to your records, or have other concerns about your privacy rights, you may contact Dr. Celina Marciano, MFT, PsyD., at (818) 388-0102. 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 Dr. Celina Marciano, 1827 W. Verdugo Ave., Suite 202, Burbank, CA 91506.

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 goes into effect on January 1, 2018.

The material and information on this website is provided for informational purposes only. The material is not and should not be construed as legal advice. The material is not and should not be construed as providing psychotherapy or psychological treatment or psychological advice. No recipient of content from this website, clients or otherwise, should act or refrain from acting based on information from this website. The content of this website is not guaranteed as to its accuracy, completeness, or applicability. Healing Crossroads expressly disclaims all liability in respect to actions taken or not taken based on any or all of the contents of this website.