Info@balancingacttherapy.com

Phone: 408-915-0111

Campbell, CA 95008

Notice of Privacy Practices

EFFECTIVE DATE OF THIS NOTICE: January 11, 2025

This notice describes how health information may be used and disclosed and how you can get access to this information. 

I. OUR COMMITMENT TO YOUR PRIVACY: 

We understand that health information about you and your health care is personal. We are committed to protecting the privacy of your protected health information. We create a record of the care and services you receive from me. We 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 mental health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to: 

  • Maintaining the confidentiality of your protected health information (“PHI”). 
  • Give you this notice of our legal duties and privacy practices with respect to health information.
  • Follow the terms of the Notice that is currently in effect. 

We reserve the right to change the terms of this Notice, and such changes will apply to all information we have about you, as well as any information we receive in the future. The new Notice will be available upon request, in our office, and on our website. 

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: 

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. 

For Treatment, Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the client to use or disclose the client’s personal health information without the patient’s written authorization for the following. 

  1. To provide you with mental health treatment or services, including coordinating care with other healthcare providers and consultations with another healthcare provider.
    • We may share more of your health information than the minimum required when it is needed for your treatment. Sometimes therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another. 
  2. To bill and collect payment for services provided. 
  3. For our practice operations, such as quality assessment and improvement activities. 

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: 

  1. Psychotherapy Notes: We do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: 
    • For our use in treating you. 
    • For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. 
    • For our use in defending ourselves in legal proceedings instituted by you. 
    • For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA. 
    • Required by law and the use or disclosure is limited to the requirements of such law. 
    • Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
    • Required by a coroner who is performing duties authorized by law. 
    • Required to help avert a serious threat to the health and safety of others. 
  2. Marketing Purposes: We will not use or disclose your PHI for marketing purposes. 
  3. Sale of PHI: We will not sell your PHI in the regular course of our business. 

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. 

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

  1. For Compliance with the Law: When disclosure is required by state, federal, or local law, and the use or disclosure complies with and is limited to the relevant requirements of such law. 
  2. To Avert Serious Threats to Health or Safety / For Abuse or Neglect: When necessary to prevent serious threats to you or others, including reporting suspected child, elder, or dependent adult abuse or neglect, or preventing or reducing a serious threat to anyone’s health or safety.
  3. For Public Health Activities: Including preventing or controlling disease. 
  4. For Health Oversight Activities: To health oversight agencies for activities authorized by law, including audits and investigations. 
  5. 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. 
  6. For Law Enforcement Purposes: To law enforcement officials in certain circumstances, including reporting crimes occurring on our premises. 
  7. To Coroners, Medical Examiners, or Funeral Directors: When such individuals are performing duties authorized by law, including identifying a deceased person or determining cause of death. 
  8. For Research Purposes: For research projects that have been approved by an institutional review board, 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. 
  9. For Organ and Tissue Donation: To organizations that handle organ procurement. 
  10. For Specialized Government Functions: As required by military command authorities if you are a member of the armed forces, including ensuring the proper execution of military missions, protecting the President of the United States, conducting intelligence or counterintelligence operations, or helping to ensure the safety of those working within or housed in correctional institutions.
  11. For National Security and Intelligence Activities: To authorized federal officials for intelligence, counterintelligence, and other national security activities. 
  12. For Workers’ Compensation purposes: For workers’ compensation or similar programs in order to comply with laws, although our preference is to obtain an Authorization from you. 
  13. To Correctional Institutions: To the institution or its agents if you are or become an inmate of a correctional institution. 
  14. For Appointment Reminders: To contact you as a reminder that you have an appointment. 
  15. For Health-Related Benefits and Services: To inform you about health related-beenefits, alternatives, or services that may be of interest to you. 

V. 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. 

VI. 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 affect your health care or our practice operations. 

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. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. 

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 to 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.

To Exercise any of these rights, please submit your request in writing to our Privacy Officer.  

Uses Requiring Authorization: We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any other uses and disclosures not described in this Notice of Privacy Practices will be made only with your written authorization.

Revocation of Authorization: You may revoke any authorization at any time, in writing, except to the extent that we have already taken an action in reliance on the use or disclosure indicated in the authorization.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact our Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Privacy Officer Contact Information 
Isabel Chavez
Address: 125 E SunnyOaks Ave, Suite 101 Campbell, CA 95008
Phone: 408-915-5158
Email: operations@balancingacttherapy.com