Client Intake · Step 2 of 2

Notice of Privacy Practices

Please read this notice carefully. It describes how health information about you and your child may be used and disclosed, and explains your rights. Acknowledge receipt using the form at the bottom.

AJG Behavioral Services
adamg@ajgbehavioral.com  ·  (559) 622-4408
This notice describes how your health information may be used and disclosed and how you can get access to this information. Please review it carefully. You may have additional rights under state and local law.

Acknowledgment of receipt of privacy notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information ("PHI").

I. My pledge regarding health information

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I 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 this practice.

I am required by law to:

  • Make sure that PHI that identifies you is kept private.
  • Give you this notice of my legal duties and privacy practices with respect to health information.
  • Follow the terms of the notice that is currently in effect.
  • I can change the terms of this Notice, and such changes will apply to all the information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. How I may use and disclose health information about you

The following categories describe different ways that I use and disclose health information. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For treatment, payment, or health care operations: Federal privacy rules allow health care providers who have a direct treatment relationship with the patient/client to use or disclose the patient/client's personal health information without written authorization, to carry out the health care provider's own treatment, payment, or health care operations. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your PHI in order to assist in diagnosis and treatment. I may also use your PHI for operations purposes, including sending appointment reminders and billing invoices.

Disclosures for treatment purposes are not limited to the minimum necessary standard because providers need access to the full record in order to provide quality care. The word "treatment" includes the coordination and management of health care providers with a third party, consultations between providers, and referrals from one health care provider to another.

Lawsuits and disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order, or in response to a subpoena, discovery request, or other lawful process, but only if efforts have been made to tell you about the request or to obtain a protective order.

III. Certain uses and disclosures require your authorization

  1. Psychotherapy notes. Any use or disclosure of psychotherapy notes requires your authorization unless the use or disclosure is: for my use in treating you; for training or supervising practitioners; for defending myself in legal proceedings you institute; required by the Secretary of HHS; required by law; required for certain health oversight activities; required by a coroner performing duties authorized by law; or required to help avert a serious threat to health and safety.
  2. Marketing purposes. I will not use or disclose your PHI for marketing purposes without your prior written consent. If I request a review from you and plan to share it publicly, I will provide a HIPAA authorization. You may withdraw consent at any time in writing.
  3. Sale of PHI. I will not sell your PHI.

IV. Uses and disclosures that do not require your authorization

Subject to certain limitations in the law, I can use and disclose your PHI without your authorization for the following reasons:

  1. Appointment reminders and health-related benefits or services. I may contact you to remind you of appointments or tell you about treatment alternatives or other health care services I offer.
  2. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
  3. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone's health or safety.
  4. For health oversight activities, including audits and investigations.
  5. For judicial and administrative proceedings, including responding to a court order or subpoena, although my preference is to obtain authorization from you first if permitted.
  6. For law enforcement purposes, including reporting crimes occurring on my premises.
  7. To coroners or medical examiners when performing duties authorized by law.
  8. For research purposes, including studying and comparing outcomes of different treatment approaches.
  9. Specialized government functions, including ensuring the proper execution of military missions, protecting the President, conducting intelligence operations, or ensuring safety within correctional institutions.
  10. For workers' compensation purposes, although my preference is to obtain authorization first.
  11. For organ and tissue donation requests.

V. Certain uses and disclosures require you to have the opportunity to object

Disclosures to family, friends, or others: You have the right and choice to tell me that I may provide your PHI to a family member, friend, or other person involved in your care or the payment for your health care, or to share information in a disaster relief situation. The opportunity to consent may be obtained retroactively in emergency situations to mitigate a serious and immediate threat to health or safety or if you are unconscious.

VI. Your rights with respect to your PHI

  1. The right to request limits on uses and disclosures of your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations. I am not required to agree, and may say "no" if I believe it would affect your health care.
  2. The right to request restrictions for out-of-pocket expenses paid in full. You have the right to request restrictions on disclosure of your PHI to health plans for payment or operations purposes if the PHI pertains solely to a health care item or service you have paid for out-of-pocket in full.
  3. The right to choose how I send PHI to you. You have the right to ask me to contact you in a specific way or to send mail to a different address, and I will agree to all reasonable requests.
  4. The right to see and get copies of your PHI. You have the right to get an electronic or paper copy of your record and other information I have about you. I will provide a copy or summary within 30 days of receiving your written request. A reasonable cost-based fee may apply.
  5. The right to get a list of disclosures I have made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations. I will respond within 60 days. The list will include disclosures made in the last six years. The first request each year is free; additional requests in the same year may incur a reasonable fee.
  6. The right to correct or update your PHI. If you believe there is a mistake or missing information in your PHI, you have the right to request a correction. I may say "no" but will tell you why in writing within 60 days.
  7. The right to get a paper or electronic copy of this notice. You have the right to get a paper copy of this Notice at any time, even if you agreed to receive it electronically.
  8. The right to choose someone to act for you. If you have given someone medical power of attorney or they are your legal guardian, that person can make choices about your health information.
  9. The right to revoke an authorization. You may revoke any authorization you have given me at any time, in writing.
  10. The right to opt out of communications and fundraising. You have the right to opt out of certain communications from our organization.
  11. The right to file a complaint. You can file a complaint if you feel I have violated your rights by contacting me using the information above, or by filing a complaint with the HHS Office for Civil Rights at 200 Independence Avenue, S.W., Washington D.C. 20201, by calling (877) 696-6775, or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints. I will not retaliate against you for filing a complaint.

VII. Changes to this notice

I can change the terms of this Notice, and such changes will apply to all the information I have about you. The new Notice will be available upon request, in my office, and on my website.

Acknowledgment of receipt

By submitting this form, I acknowledge that I have received and reviewed the AJG Behavioral Services Notice of Privacy Practices.

Questions? adamg@ajgbehavioral.com  ·  (559) 622-4408