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. 

We are required by law to maintain the privacy and security of your protected health information (“PHI”) and to provide you with this Notice of Privacy Practices (“Notice”). We must abide by the terms of this Notice, and we must notify you if a breach of your unsecured PHI occurs. We can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website.

Except for the specific purposes set forth below, we will use and disclose your PHI only with your written authorization (“Authorization”). It is your right to revoke such Authorization at any time by giving us written notice of your revocation.

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Uses (Inside Practice) and Disclosures (Outside Practice) Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Written Consent. 
We can use and disclose your PHI without your Authorization for the following reasons:
1. For your treatment: We can use and disclose your PHI to treat you, which may include disclosing your PHI to another health care professional. For example, if you are being treated by a physician or a psychiatrist, we can disclose your PHI to him or her to help coordinate your care, although our preference is for you to give me an Authorization to do so. 
2. To obtain payment for your treatment: We can use and disclose your PHI to bill and collect payment for the treatment and services provided by us to you. For example, we might send your PHI to your insurance company to get paid for the health care services that we have provided to you, although our preference is for you to give us Authorization to do so. 
3. For health care operations: we can use and disclose your PHI for purposes of conducting health care operations pertaining to our practice, including contacting you when necessary. For example, we may need to disclose your PHI to my attorney to obtain advice about complying with applicable laws.

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Certain Uses and Disclosures Require Your Authorization:
1. Psychotherapy Notes: We keep a record of your treatment and you may request a copy of such record at any time, or you may request that we prepare a summary of your treatment. There may be reasonable, cost-based fees involved with copying the record or preparing the summary. 
2. Marketing Purposes:  As Therapists, we will not use or disclose your PHI for marketing purposes. 
3. Sale of PHI: As Therapists, we will not sell your PHI under any circumstances.

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Certain Uses and Disclosures Do Not Require Your Authorization. Subject to certain limitations mandated by law, we can use and disclose your PHI without your Authorization for the following reasons:
1. 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.  
2. 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. 
3. For health oversight activities, including audits and investigations.  
4. For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain an Authorization from you before doing so. 
5. For law enforcement purposes, including reporting crimes occurring on my premises.  
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition. 
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.     
9. For workers' compensation purposes. Although our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers' compensation laws. 
10. Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.

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YOUR RIGHTS YOUR REGARDING YOUR PHI


You have the following 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 us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would impact your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full: You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full. 
3. The Right to Choose How We Send PHI to You: You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI: Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you.  
We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost-based fee for doing so.
5. The Right to Get a List of the Disclosures We Have Made.: You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost-based fee for each additional request.
6. The Right to Correct or Update Your PHI:  If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information.  We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice: You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

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Certain Uses and Disclosures Require You to Have the Opportunity to Object:
1. Disclosures to family, friends, or others: We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

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According to the State's governing board, we participate in ongoing Supervision with Supervisors and/or colleagues. Some of these meetings will take place virtually through audio and/or video. These sessions will not be recorded.  By signing this agreement, you acknowledge that you understand that some sessions will involve other therapists who follow the same confidential policy that we do, for which you have already acknowledged understanding of and consent in the opening paperwork completed at the beginning of treatment.
You may revoke this consent* at any time except to the extent that action based on this consent has been taken. This authorization is fully understood and is made voluntarily.

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HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES

If you think we may have violated your privacy rights, you may file a complaint with us, as the Privacy Officer for our practice, and our address and telephone number are: 
Left Coast Wellness
1355 Oak Street, Suite 100  Eugene, OR 97401
(541) 600-4151

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You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:
Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201; 
Calling 1-877-696-6775; or,
Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

We will not retaliate against you if you file a complaint about our privacy practices.