b. For my use in training or supervising other mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law, and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
If you think I may have violated your privacy rights, you may file a complaint with me, as the Privacy Officer for my practice:
I will not retaliate against you if you file a complaint about my privacy practices.
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Santa Cruz Clinical Social Work Service
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.
Santa Cruz Clinical Social Work Service is a group network of independently practicing local professional licensed clinical social workers (LCSW) specializing in behavioral health care to the Medicare Patient Population.
Santa Cruz Clinical Social Work Service (SCCSWS) 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 (“SCCSWS Notice”). SCCSWS must abide by the terms of this Notice, and must notify you if a breach of your unsecured PHI occurs. SCCSWS can change the terms of this Notice, and such changes will apply to all information about you. The new Notice will be available upon request, at office, and on this website.
It should be noted that this Notice only applies to SCCSWS operations. Your primary independently licensed psychotherapist/LCSW will also have a separate Notice of Privacy Practices detailing how they utilize and protect your PHI and PII.
As independently licensed and practicing clinical social workers, you may also make complaints or seek consumer protections from the CA Board of Behavioral Sciences.
You may contact the board on-line at
www.bbs.ca.gov or by calling (916) 574-7830
Except for the specific purposes set forth below, SCCSWS 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 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.
SCCSWS can use and disclose your PHI without your Authorization for the following reasons:
1. For your treatment. SCCSWS can use and disclose your PHI to treat you, which may include disclosing your PHI to another health care professional(s). For example, if you are being treated by a physician or a psychiatrist, SCCSWS can disclose your PHI to him or her to help coordinate your care.
2.
To obtain payment for your treatment. SCCSWS can use and disclose your
PHI to bill and collect payment for the treatment and services provided by me
to you. For example, SCCSWS might send your PHI to your insurance company to
get paid for the health care services that have provided to you, although the preference
is for you to give an Authorization to do so.
3. For health care operations. SCCSWS can use and disclose your PHI for purposes of conducting health care operations, including contacting you when necessary. For example, SCCSWS may need to disclose your PHI to an attorney to obtain advice about complying with applicable laws.
Certain Uses and Disclosures Require Your Authorization.
1. Psychotherapy Notes. SCCSWS does not retain psychotherapy notes. Please check with your primary psychotherapist/LCSW and review their notice to determine if they keep psychotherapy notes.
2. Marketing Purposes. SCCSWS will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. SCCSWS will not sell your PHI in the regular course of business.
Certain Uses and Disclosures Do Not Require Your Authorization.
Subject to certain limitations in the law, SCCSWS 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 the preference is to obtain an Authorization
from you before doing so.
5.
For law enforcement purposes, including reporting crimes occurring on the premises
or in the community.
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. Although the preference is to obtain an
Authorization from you, SCCSWS may provide your PHI in order to comply with
workers' compensation laws.
10. Appointment reminders and health related benefits or services. SCCSWS may use and disclose your PHI to contact you to remind you that you have an appointment.
Certain Uses and Disclosures Require You to Have the
Opportunity to Object.
1. Disclosures to family, friends, or others. SCCSWS 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 YOUR 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 SCCSWS not to use or disclose certain PHI for treatment, payment, or health care operations purposes. SCCSWS is not required to agree to your request, and may say “no” if it is believed that this information 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 SCCSWS Sends PHI to You. You have the right to ask SCCSWS to contact you in a
specific way (for example, home or office phone) or to send mail to a different
address.
4. The Right to See and Get Copies of Your PHI. You have the right to get an electronic or paper copy of your medical record and other information that SCCSWS has retained. SCCSWS is the custodian of records for services provided to you by your primary psychotherapist/LCSW. SCCSWS 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 SCCSWS may charge a reasonable, cost based fee for doing so.
5.
The Right to Get a List of the Disclosures SCCSWS Has Made. You have the right to request a list of instances in
which SCCSWS has disclosed your PHI for purposes other than treatment, payment,
or health care operations, or for which you provided me with an Authorization. SCCSWS
will respond to your request for an accounting of disclosures within 60 days of
receiving your request. The list SCCSWS will give you will include disclosures
made in the last six years unless you request a shorter time. SCCSWS will
provide the list to you at no charge, but if you make more than one request in
the same year, SCCSWS may 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 correction to the existing information or to add the missing information. SCCSWS 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 PRIVACY PRACTICES
Any question, concerns, or complaints about your privacy rights, may be addressed by contacting or writing to the SCCSWS Privacy Officer:
David A. Resnikoff MSW, LCSW
PO BOX 514
Santa Cruz, CA 95061-0514
Phn: 831-471-5044
david.resnikoff.lcsw@gmail.com
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. Calling 1-877-696-6775; or,
3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.
SCCSWS will not retaliate
against you if you file a complaint.
EFFECTIVE DATE OF THIS NOTICE: 01/18/2020
