Chiron Psychological, Inc.
Psychological Services for Individuals, Couples, and Families
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.
Chiron is 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”). Chiron
must abide by the terms of this Notice, and Chiron must notify you if a breach of your
unsecured PHI occurs. Chiron can change the terms of this Notice, and such changes will
apply to all information Chiron has about you. The new Notice will be available upon request,
in the office, and on our website.
Except for the specific purposes set forth below, Chiron 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 our office a written notice of your revocation.
Uses (Inside Practice) and Disclosures (Outside Practice) Relating to Treatment,
Payment, or Health Care Operations Do Not Require Your Written Consent. Chiron can
use and disclose your PHI without your Authorization for the following reasons:
1. For your treatment. Chiron 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, Chiron can disclose your PHI to him or her to help coordinate
your care, although our preference is for you to provide an Authorization to do so.
2. To obtain payment for your treatment. Chiron can use and disclose your PHI to bill and
collect payment for the treatment and services provided by me to you. For example, Chiron
might send your PHI to your insurance company to get paid for the health care services that
Chiron have provided to you.
3. For healthcare operations. Chiron can use and disclose your PHI for purposes of
conducting health care operations pertaining to our practice, including contacting you when
necessary. For example, Chiron may need to disclose your PHI to our attorney to obtain
advice about complying with applicable laws.
Certain Uses and Disclosures Require Your Authorization.
1. Psychotherapy Notes. Chiron does not keep “psychotherapy notes” as that term is defined
in 45 CFR § 164.501; rather, Chiron keeps a record of your treatment and you may request a
Client Copy
copy of such record at any time, or you may request that Chiron 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. Chiron will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. Chiron will not sell your PHI in the regular course of my business.
Certain Uses and Disclosures Do Not Require Your Authorization. Subject to certain
limitations mandated by law, Chiron 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. Chiron may provide your PHI in order to comply
with workers' compensation laws.
10. Appointment reminders and health related benefits or services. Chiron may use and
disclose your PHI to contact you to remind you that you have an appointment. Chiron
may also use and disclose your PHI to tell you about treatment alternatives, or other
health care services or benefits.
Certain Uses and Disclosures Require You to Have the Opportunity to Object.
1. Disclosures to family, friends, or others. Chiron 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.
YOUR RIGHTS 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. Chiron is not required to agree to your request, and
may say “no” if it would affect 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 Chiron
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. Chiron 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 may charge a reasonable, cost based fee
for doing so.
5. The Right to Get a List of the Disclosures Chiron Has Made.
You have the right to request a list of instances in which Chiron has disclosed
your PHI for purposes other than treatment, payment, or health care operations,
or for which you provided me with an Authorization. Chiron will respond to your
request for an accounting of disclosures within 60 days of receiving your request.
The list will include disclosures made in the last six years unless you request a
shorter time. Chiron will provide the list to you at no charge, but if you make more
than one request in the same year, Chiron 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 Chiron corrects the existing information or add the
missing information. Chiron may say “no” to your request, but 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.
HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
If you think we may have violated your privacy rights, you may file a complaint with our office
attn: Ray Weaver, as the Privacy Officer for the practice, and the address and telephone
number are: 18200 Yorba Linda Blvd. Suite 111 Yorba Linda 92886; (714) 646-8034
___________________________________________________________________________________________________.
You can also file a complaint with the U.S. Department of Health and Human Services Office
for Civil Rights by:
1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;
2. Calling1-877-696-6775; or,
3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.
We will not retaliate against you if you file a complaint about my privacy practices.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on September 1, 2017.
Limitations To Confidentiality
There are some situations in which a therapist is legally obligated to breach confidentiality.
These situations may include:
1. If a therapist knows or has reason to suspect a minor child, elder, or dependent adult is
being neglected or abused, the law requires that a report is filed immediately with the
appropriate government agency, usually the county Child Protective Services or Adult
Protective Services. Once such a report is filed, your therapist may be required to provide
additional information.
2. If your therapist suspects that you present a serious and specific threat of physical harm or
violence to yourself or another person, it may be required to disclose information necessary
to keep you safe or others safe. These actions may include notifying the potential victim,
contacting your family or others who can help provide protection, contacting the police, or
seeking your hospitalization.
3. When a judge issues a COURT ORDER to release a client file. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important to discuss any questions or concerns that you may have now or in the future with your therapist. Should you wish information to be released to any person(s) or agencies, you will be required to sign a CONSENT TO RELEASE INFORMATION form.