FOUNDATIONS COUNSELING SERVICES

• • • Email : maryann@foundations-counseling.com Website: http://foundations-counseling.com

MaryAnn McCoy, MS, LPCC 28780 Single Oak Drive Ste. 217 Temecula, Ca. 92590 (951) 363-5255  maryann@foundations-counseling.com

Notice of Privacy Practices

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 HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).

We are legally required to protect the privacy of your PHI, which includes information that can be used to identify you and that we have created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of this health care. We must provide you with this notice about our privacy practices, and this notice must explain how, when, and why we will "use" and "disclose" your PHI. A "use" of PHI occurs when we share, examine, utilize, apply, or analyze our practice. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure was made. And we are legally required to follow the privacy practices described in this Notice. However, we reserve the right to change the terms of this Notice, and our privacy policies at any time. Any changes will apply to all PHI already on file. Before we make any important changes to the privacy policies, we will promptly change this notice and post a new copy in our office and on our website. You can also request a new copy of this notice in our office at any time.

HOW WE MAY USE AND DISCLOSE YOUR PHI.

We will use and disclose your PHI for many different reasons. For some of these uses or disclosures, we will need your prior authorization for others however, we do not. Listed below are the different categories of our uses and disclosures along with some examples of each category.

USES AND DISCLOSURES RELATING TO TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS DO NOT REQUIRE YOUR PRIOR WRITTEN CONSENT. We can use and disclose your PHI without your consent for the following reasons:

•FOR TREATMENT. We can use and disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your case. We can disclose your PHI to your physician in order to coordinate your care.

•TO OBTAIN PAYMENT FOR TREATMENT. We can use and disclose your PHI to bill and collect payment for the treatment and services provided to you. For example, we might send your PHI to your insurance company or health plan to get paid for the health care we have provided to you. We may also provide your PHI to our business associates, such as billing companies, claim processing companies, and others that process our health care claims.

•FOR HEALTH CARE OPERATIONS. We can use or disclose your PHI to operate our practice. For example, we might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. We may also provide your PHI to our accountants, attorneys, consultants, and others to make sure we are complying with applicable laws.

•OTHER DISCLOSURES. We may also use or disclose your PHI to others without your consent in certain situations. For example your consent is not required if you need emergency treatment, as long as we try to get your consent after treatment is rendered, or if we try to get your consent but you are unable to communicate with us (such as if you are unconscious or in acute pain) and we believe you would consent to such treatment if you were able to do so.

CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR CONSENT. We can use and disclose your PHI without your consent or authorization for the following reasons:

•WHEN DISCLOSURE IS REQUIRED BY FEDERAL, STATE, OR LOCAL LAW; JUDICIAL OR ADMINISTRATIVE PROCEEDINGS; LAWENFORCEMENT. For example, we may make a disclosure to applicable officials when a law requires us to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding.

•FOR PUBLIC HEALTH ACTIVITCES. For example, we may have to report information about you to the county coroner.

•FOR HEALTH OVERSIGHT ACTIVITIES. For example, we may have to provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization.

•FOR RESEARCH PURPOSES. In certain circumstances, we may provide PHI in order to conduct medical research.

•TO AVOID HARM. In order to avoid a serious threat to the health or safety of a person or the public. We may need to provide PHI to law enforcement personnel or persons able to prevent or lessen such harm.

•FOR SPECIFIC GOVERNMENT FUNCTIONS. We may disclose PHI of military personnel and veterans in certain situations. And we may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations.

•FOR WORKERS COMPENSATION PURPOSES. We may disclose PHI in order to comply with workers' compensation laws.

•APPOINTMENT REMINDERS AND HEALTH RELATED BENEFITS AND SERVICES. We may use PHI to provide appointment reminders or give you information about treatment alternatives or other health care services or benefits we offer.

•CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

•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 case 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.

•OTHER USES AND DISCLOSURES REQUIRE YOUR PRIOR WRITTEN AUTHORIZATION.

ln any other situation not previously described in this section we will ask for your written authorization before using or

our disclosing PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing and stop any future uses and disclosures (to the extent that we haven't already taken any action in reliance on such authorization).

•WHAT RIGHTS YOU HAVE REGARDING YOUR PHI.

You have the following rights with respect to your PHI.

•THE RIGHT TO REQUEST LIMITS ON USES AND DISCLOSURES OF PHI. You have the right to ask that we limit how we use your PHI.

We will consider your request, but we are not legally required to accept it. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make.

•THE RIGHT TO CHOOSE HOW WE SEND PHI TO YOU. You have the right to ask that we send information to you at an alternative

address (such as sending information to your work address rather than your home address) or by alternate means (such as email rather than regular mail). We must agree to your request so long as we can easily provide the PHI to you in the format and method you have requested.

•THE RIGHT TO SEE AND GET COPIES OF YOUR PHI. In most cases, you have the right to look at or get copies of your PHI that we have,

but you must make the request in writing. If we do not have your PHI but we know who does, we will tell you how to get it. We will respond to you within30 days after receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for the denial and explain your right to have the denial reviewed.

•lf you request copies of your PHI we will charge you not more than $25.00 for electronic transmission of records. Instead of providing the

PHI you requested, we may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance.

•THE RIGHT TO GET A LIST OF THE DISCLOSURES WE HAVE MADE. You have the right to get a list of instances in which we have disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for

treatment, payment, or health care operations, directly to you, or to your family. The list will also not include uses and disclosures made for

national security purposes, to corrections or law enforcement personnel, or disclosures prior to April I 5th, 2003.

•We will respond to your request for a list 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. The list will include the date of the disclosure, to whom the PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide this 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

•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, you have the right to request that we correct the existing information or add the missing information. You must provide the request and the reason for the request in writing. We will respond within 60 days of receiving your request to correct or update your PHI. We may deny your request inwriting if the PHI is (i) correct and complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not part of our records. Our written denial will state the reason for the denial and explain your right to file a written statement of disagreement with the denial. If you do not file one, you have the right to request that your request and our denial be attached to all future disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done so, and tell others that need to know about the change to your PHI.

•THE RIGHT TO GET THIS NOTICE BY EMAIL you have the right to get a copy of this notice by email. Even if you have agreed to receive this

notice via email, you also have the right to request a copy of it by mail.

•HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES.

If you think that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed below. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200Independence Avenue S.W., Washington D.C. 20201. We will take no retaliatory action against you if you file a complaint about our privacy practices.

•PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES.

If you have any questions about this notice or any complaints about our privacy practices or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact our Office Manager at 951-363-5255.

Acknowledgement of Receipt of Notice of Privacy Practices

Patient or SubscriberName: __________________________________________________________

(Please print patient or subscriber name)

I, _____________________________________________________________________________

(Print name of patient, subscriber, conservator, parent or legal guardian signing below)

Acknowledge receipt of the Notice of Privacy practices, which explains limits on ways in which Foundations Counseling Services may use or disclose personal health information (PHI) to provide service.

Signature: ________________________________________ Date: _________________________

If not signed by patient, indicate relationship: ___________________________________________

NOTE: Parent must has legal custody. Legal guardians and conservators must show proof

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THIS SECTION TO BE FILLED OUT BY FOUNDATIONS COUNSELING SERVICES STAFF

Patient did receive the Notice of Privacy Practices, but did not sign this Acknowledgment of Receipt because:

⎕ Patient left office before Acknowledgment could be signed.

⎕ Patient did not wish to sign this form.

⎕ Patient cannot sign this form because: _____________________________________________________________________________________________

Patient did not receive the Notice of Privacy Practices because:

⎕ Patient required emergency treatment.

⎕ Patient declined the Notice and signing this Acknowledgement.

⎕ Other: _____________________________________________

Name: ___________________________________________________ Signature: ______________________________________ Date: __________________