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

NOTICE OF PRIVACY PRACTICES

As a provider of Mental Health services Daniel Gomez is required to protect your privacy and provide you with this notice of the steps we take to assure that your personal health information is kept confidential.

This Notice describes your rights and our obligations regarding the use and disclosure of your health information. Over time we may revise this Notice however, if we do, we are required to inform you of our new privacy policy by making a revised Notice available to you. Copies of the Notice can be obtained in our office. All persons who receive services will be asked to sign or re-sign a “Consent for Treatment”, which will serve as your acknowledgement of this Notice.

When you come to Daniel Gomez , a record of your treatment is started. This record contains “demographic information” (such as name, address, telephone number, social security number, birth date and health insurance information) as well as other information including why you have come to our program, how you say you feel, what health problems you have, treatments you may have received, observations by health care providers, diagnosis and plan of care. This information is known as Protected Health Information, or PHI, and is used for a number of purposes that are explained in more detail in this Notice. We do not sell your PHI and we take steps to protect your PHI from people who do not need or have the legal right to see it.

TREATMENT, PAYMENT AND OPERATIONS
We may use your PHI for treatment, payment purposes, or for agency operations making reasonable efforts to limit the use and disclosure of PHI to the minimum amount necessary to accomplish the intended purpose. This is covered when you sign the “Consent for Treatment” form at intake. All current service partners will sign a revised “Consent for Treatment” form upon receipt of this Notice. Your signed “Consent for Treatment” form will be your Authorization for the use and disclosure of your PHI for treatment, payment purposes, or for agency operations according to the following definitions.

Treatment: Your PHI will be used to provide, coordinate, or manage your care and related services. This includes the coordination or management of your treatment with another person like a doctor or therapist.
Payment: Your PHI will be used and disclosed to obtain payment for the services we have provided. This may include communications to your health insurer to obtain approval for treatment. or may include statistical reports to agencies making funds available to us for your benefit.
Operations: We may use your PHI within our agency in order to maintain or improve services. This can include quality assessment, accreditation, licensing or business management and general administrative activities.

Other uses and disclosures covered by your treatment, payment and operations Authorization include:
• Calls to remind you of an appointment and messages left on answering machines if you do not answer the telephone.
• To inform you of potential treatment options.
• To inform you of health benefits or services that may be of interest to you.
• To provide training to health professional students who are working in our agency.
Notice of Privacy Practices continued


At times, either Daniel Gomez or you may wish to use your PHI for a reason not identified above. In those cases, a special Authorization will be needed. If your PHI is requested for a use that requires a special Authorization, you will be told why your information is requested, who is asking for the information, and what information is requested. You will also be told how you may cancel your Authorization. If we have already acted on an Authorization you gave us earlier, your cancellation will affect information release for the future.

YOUR INFORMATION RIGHTS
In addition to the Authorizations already discussed, you have specific rights related to you Protected Health Information (PHI). These are:
• Right to Request Restriction of Uses and Disclosures: You may request limitations on the uses of your PHI. For example, you can ask that your information not be shared with certain family members. We are not always able to comply with these requests however, if we are unable or do not agree to your request, we will let you know. If we do agree to a restriction, and the restricted information is needed for your emergency care, we may still use or disclose the information as we think appropriate.
• Right to Request Alternate Methods of Communication: You may request an alternate method of receiving confidential mailings and other communications of your health information. For instance, you may request that your health information be sent to your office or to a post office box rather than to your home address. You may also request that calls be made to a certain telephone number. We do not require that you state a reason for your request.
• Right to Access PHI: You may request to review your PHI and obtain a copy. This request is made in writing to your counselor. If your request is accepted, we will arrange a mutually agreeable time for you to look at your health information. We may deny your request to review and copy in a few limited circumstances however, if your request is denied, you may ask for a review of that denial by contacting the Clinical Supervisor. A reasonable fee may be required for copies of health information. We will let you know what the fee will be before any copies are made.
• Right to Request an Amendment to Your PHI: You may request an Amendment to your health information if you think it is incorrect or incomplete. We will ask that the request be in writing and state the reasons for the amendment. We will notify you to let you know if we agree or disagree with your request. If we do not agree, we will provide you with information on why we disagree and what options you have. To request an amendment, please contact our privacy officers at the location where you receive services.
• Right to an Accounting of Disclosures of PHI. You have the right to request a periodic accounting of the disclosures of your health information so that you will be aware of who has had access to your information. Your request may specify a time period up to six years. We are not required to provide an accounting for disclosures prior to April 14, 2003 and not every disclosure included in an accounting. Disclosures you authorized in writing, routine internal disclosures such as those made to agency personnel in the course of providing you services, and/or disclosures made in connection with payment are all examples of things not included in the accounting. The accounting will state the time of the disclosure, the purpose for which it was disclosed and a description of the information disclosed. If there is any fee for the accounting, we will let you know what it is before the accounting is done.
• Right to Receive a Copy of this Notice: You will be offered a copy of this Notice during intake and additional copies will be available upon request at Daniel Gomez.

COMPLAINTS
If you have questions, would like additional information or feel that we have violated your privacy rights, you may contact our Privacy

Or by filing a written complaint with the:

Secretary of the U.S. Department of Health and Human Services.
200 Independence Avenue SW
Washington DC 20201

We will not retaliate against you or any person for filing a complaint or exercising your rights under the privacy regulations.

This notice is provided in accordance with the Health Insurance Portability and Accountability Act (HIPPA) of 1996 effective April 14, 2003