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.

Wellspring Family Therapy, Suzette Bray LMFT (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice’s legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

YOUR RIGHTS

Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI.

• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person’s life. You may have a right to have this decision reviewed.

To amend PHI.

• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications.

• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared.

• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared.

• You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice.

• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you.

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

To file a complaint if you feel your rights are violated.

• You can file a complaint by contacting the Practice using the following information:

Wellspring Family Therapy, Suzette Bray LMFT
11333 Moorpark St. #462
Studio City, CA 91602
Suzette Bray, LMFT
323 449 3044

You can 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/.
The Practice will not retaliate against you for filing a complaint.

To opt out of receiving fundraising communications.

• The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.

OUR USES AND DISCLOSURES

Routine Uses and Disclosures of PHI

The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

To treat you.

• The Practice can use and share PHI with other professionals who are treating you.
  Example: Your primary care doctor asks about your mental health treatment.

To run the health care operations.

• The Practice can use and share PHI to run the business, improve your care, and contact you.
  Example: The Practice uses PHI to send you appointment reminders if you choose.

To bill for your services.

• The Practice can use and share PHI to bill and get payment from health plans or other entities.
  Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to ObjectThe Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

• To help with public health and safety issues

  • Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
  • Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
  • Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
  • Serious threat to health or safety: To prevent a serious and imminent threat.
  • Abuse or Neglect: To report abuse, neglect, or domestic violence.

• To comply with law, law enforcement, or other government requests

  • Required by law: If required by federal, state, or local law.
  • Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request.
  • Law enforcement: To locate and identify you or disclose information about a victim of a crime.

     

This Notice is effective on 1/31/2023.