HIPAA Notice of Privacy Practices

Anne Rose, LMFT (#97472) is a licensed psychotherapist providing telehealth services throughout California. As a covered health care provider under HIPAA, I am required by law to maintain the privacy of your Protected Health Information (PHI), provide you with this Notice of Privacy Practices, and follow the terms of this Notice.

I use and disclose your PHI for the following purposes:

• Treatment: To provide, coordinate, or manage your mental health care, including sharing information with other health care providers involved in your treatment with your consent.
• Payment: To obtain payment for services, including submitting claims to insurance companies or other payers.
• Health Care Operations: For quality assessment, training, licensing, and other operational activities necessary to run my practice.

I will obtain your written authorization before using or disclosing your PHI for purposes other than treatment, payment, or health care operations, including:

• Most disclosures of psychotherapy notes
• Marketing purposes
• Sale of your PHI
• Any other use or disclosure not described in this Notice

You may revoke any authorization in writing at any time, except to the extent I have already acted in reliance on it.

California and federal law permit or require disclosure of PHI without your authorization in certain circumstances, including:

• Mandatory Reporting: Suspected child abuse, elder abuse, or dependent adult abuse
• Duty to Warn/Protect: If you present a serious and imminent threat to yourself or others
• Court Orders: In response to a valid court order or subpoena
• Public Health Activities: As required by law
• Law Enforcement: As required or permitted by law

You have the following rights with respect to your PHI:

• Right to Access: You may request a copy of your health records. I may charge a reasonable fee for copies.
• Right to Amend: You may request that I amend your health information if you believe it is incorrect or incomplete.
• Right to an Accounting of Disclosures: You may request a list of certain disclosures I have made of your PHI.
• Right to Request Restrictions: You may request restrictions on how I use or disclose your PHI, though I am not required to agree to all requests.
• Right to Confidential Communications: You may request that I communicate with you in a specific way or at a specific location.
• Right to a Paper Copy of This Notice: You may request a paper copy of this Notice at any time.
• Right to Notification of Breach: You have the right to be notified in the event of a breach of your unsecured PHI.

I am required by law to:

• Maintain the privacy and security of your PHI
• Provide you with this Notice of Privacy Practices
• Follow the terms of this Notice
• Notify you if there is a breach of your unsecured PHI

I reserve the right to change this Notice. Any revised Notice will apply to PHI I already have about you as well as any PHI I receive in the future. A current copy will always be available upon request and posted on my website.

If you believe your privacy rights have been violated, you may file a complaint with me or with the U.S. Department of Health and Human Services Office for Civil Rights. You will not be retaliated against for filing a complaint.

HHS Office for Civil Rights:
www.hhs.gov/ocr/privacy/hipaa/complaints