CALIFORNIA NOTICE FORM

Notice of Privacy Practices

This notice describes how health/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 the Privacy Officer

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

The Center for Aging Resources is committed, whenever possible, to keep the health/mental health information contained in your record private.

The Center for Aging Resources may, however use or disclose your health/mental health information, for certain treatment, payment, and health care operations purposes without your authorization. In certain circumstances the Center can only do so when the person or business requesting your health/mental health information gives your clinician a written request that includes certain promises regarding protecting the confidentiality of your health/mental health information. To help clarify these terms, here are some definitions:

· “Protected Health Information (PHI)” refers to information in your health/mental health information in your record that could identify you.

“Treatment and Payment Operations”

-Treatment is when your clinician or another healthcare provider diagnoses or treats you. An example of treatment would be when your clinician consults with another health care provider, such as your family physician or another psychologist, regarding your treatment.

-Payment is when your clinician obtain reimbursement for your healthcare.  Examples of payment are when the Center discloses your health/mental health information to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

-Health Care Operations is when the Center discloses your health/mental health information to your health care service plan (for example your health insurer), or to your other health care providers contracting with your plan, for administering the plan, such as case management and care coordination.

· “Use” applies only to activities within the Center such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

· “Disclosure” applies to activities outside of the Center, such as releasing, transferring, or providing access to information about you to other parties.

“Authorization” means written permission for specific uses or disclosures.

II.  Uses and Disclosures Requiring Authorization

The Center may use or disclose health/mental health information for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained.  In those instances when the Center is asked for information for purposes outside of treatment and payment 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 your clinician made about your conversation 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 other protected health/mental health information (PHI).

You may revoke or modify all such authorizations (of health/mental health information or psychotherapy notes) at any time; however, the revocation or modification is not effective until your clinician receives it.

III.  Uses and Disclosures with Neither Consent nor Authorization

The Center may use or disclose Health/Mental Health Information without your consent or authorization in the following circumstances:

Child Abuse:  Whenever your clinician has knowledge of or observes a child your clinician knows or reasonably suspects, has been the victim of child abuse or neglect, s/he must immediately report such to a police department or sheriff ‘s department, county probation department, or county welfare department.  Also, if your clinician has knowledge of or reasonably suspects that mental suffering has been inflicted upon a child or that his or her emotional well‑being is endangered in any other way, your clinician may report such to the above agencies.

Adult and Domestic Abuse:  If your clinician has observed or has 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 your clinician is told by an elder or dependent adult that he or she has experienced these or if your clinician reasonably suspects such, s/he must report the known or suspected abuse immediately to the local Adult Protective Services, Long-term Care Ombudsman or the local law enforcement agency.

The Center does not have to report such an incident if:

1) staff has 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; and

2) staff is not aware of any independent evidence that corroborates the statement that the abuse has occurred; and

3) the elder or dependent adult has been 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, your clinician reasonably believes that the abuse did not occur.

Health Oversight: If a complaint is filed against the Center with the California Board of Psychology, the Board has the authority to subpoena confidential mental health information from your clinician 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 The Center has provided you, The Center must not release your information without 1) your written authorization or the authorization of your attorney or personal representative; 2) a court order; or 3) a subpoena duces tecum (a subpoena to produce records) where the party seeking your records provides The Center with a legal order showing that you or your attorney have been served with a copy of the subpoena, affidavit and the appropriate notice, and you have not notified The Center 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.  Your clinician will inform you in advance if this is the case.

Serious Threat to Health or Safety:  If you or a family member communicate to The Center a serious threat of physical violence against an identifiable victim, The Center must make reasonable efforts to communicate that information to the potential victim and the police.  If The Center has reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, The Center may release relevant information as necessary to prevent the threatened danger.

Worker's Compensation:  If you file a worker's compensation claim, The Center must furnish a report to your employer, incorporating your clinician’s 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.

Appointment Reminders: The Center may use/disclose your health/mental health information to contact you as a reminder that you have as appointment (for example, if you have an appointment with a psychiatrist, our support staff may contact you the day before as a reminder).  If you do not wish The Center to contact you for appointment reminders, please provide the Privacy Officer with alternative instructions (in writing).

For Research Purposes:  In certain circumstances, The Center may use/disclose your health/mental health information to our research staff and their designees in order to assist psychiatric/psychological research.  If you would like this use/disclosure to be limited, please inform the Privacy Officer of this in writing.

Fundraising Activities:  The Center may use health/mental health information about you to contact you and inform you about the Center’s fundraising activities.  If you do not wish to be contacted about fundraising activities, please inform the Privacy Officer of this in writing.

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 health/mental health information about you.  However, The Center is 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 health/mental health information by alternative means and at alternative locations.  (For example, you may not want a family member to know that you are being seen at the Center.  Upon your request, we could send your bills to another address.)

Right to Inspect and Copy ‑ You have the right to inspect or obtain a copy (or both) of health/mental health information in The Center’s mental health and billing records used to make decisions about your care for as long as the health/mental health information is maintained in the record.  The Center may deny your access to health/mental health information under certain circumstances, but in some cases you may have this decision reviewed.  On your request, your clinician will discuss with you the details of the request and denial process.

Right to Amend ‑ You have the right to request an amendment of health/mental health information for as long as the health/mental health information is maintained in the record.  The Center may deny your request. On your request, your clinician 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 health/mental health information for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, your clinician 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 The Center upon request, even if you have agreed to receive the notice electronically.

Center’s Duties:

The Center is required by law to maintain the privacy of health/mental health information and to provide you with a notice of your clinician’s legal duties and privacy practices with respect to health/mental health information.

The Center reserves the right to change the privacy policies and practices described in this notice.  Unless The Center notifies you of such changes, however, your clinician is required to abide by the terms currently in effect.

If The Center revises your clinician’s policies and procedures, The Center will offer you notice of the revised procedures, either in person or by mail.

V.  Complaints

If you are concerned that the Center has violated your privacy rights, or you disagree with a decision the Center made about access to your records, you may contact our Privacy Officer.

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.

VI.  Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on April 14, 2003.

The Center reserves the right to change the terms of this notice and to make the new notice provisions effective for all health/mental health information that the Center maintains.  The Center will provide you with a revised notice in person or by mail.

Center For Aging Resources - Heritage Clinic and CAPS

A Community Outreach Center for Seniors

Notice of Privacy Practices