Elizabeth Ngoc Nguyen, LMFT #149993
Effective and Last Updated Date: 12/06/2025
THIS NOTICE DESCRIBES HOW MEDICAL AND MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Our Commitment and Legal Duty

I am legally required to maintain the privacy of your Protected Health Information (PHI), which includes your medical records, mental health information, and billing details. I am required to provide you with this Notice of my legal duties and privacy practices concerning your PHI and to follow the terms of the Notice currently in effect.
I reserve the right to change the terms of this Notice. Any changes will apply to all PHI I maintain. I will provide you with a revised Notice if I make material changes.
I am also required by law to notify you following a breach of your unsecured PHI.

II. How I May Use and Disclose Your PHI Without Your Prior Written Authorization

The law permits me to use and disclose your PHI for the following purposes related to providing your treatment. The most common uses for a private practice therapist are for Treatment, Payment, and Health Care Operations (TPO).

Treatment: I may use and disclose your PHI to provide, coordinate, or manage your health care and related services. This includes coordinating your mental health care with another provider, such as a psychiatrist, physician, or another therapist. For example, I may share information with your psychiatrist to ensure the best possible integrated care.
Payment: I may use and disclose your PHI to obtain payment for the services I provide to you. This includes sending required information (e.g., a diagnosis, dates of service) to your insurance company (Health Plan) for claims processing, determining eligibility, or obtaining authorization for coverage.
Health Care Operations: I may use and disclose your PHI for activities necessary to run my practice, such as: quality improvement, business planning, general administrative activities, and arranging for legal and accounting services (e.g., consulting with a lawyer or accountant to ensure I am complying with applicable laws).

III. Mandatory Uses and Disclosures Required by Law

I must disclose your PHI when required by federal, state, or local law. These disclosures are mandatory for Licensed Marriage and Family Therapists in California and supersede the general privacy protections:

Serious Threat to Health or Safety (Duty to Warn/Protect): If I determine that you pose a serious and imminent threat of physical violence against an identifiable victim (California's Tarasoff mandate), I must make reasonable efforts to communicate that information to the potential victim and/or law enforcement. If I believe you are in danger of harming yourself, I may disclose relevant information to persons who can help prevent the threatened danger.
Child Abuse Reporting: If I, in my professional capacity, have knowledge of or suspect child abuse or neglect, I must immediately report this to the appropriate law enforcement or protective services agency (a mandated disclosure).
Elder/Dependent Adult Abuse Reporting: If I, in my professional capacity, have knowledge of or suspect abuse, neglect, or financial exploitation of an elder or dependent adult, I must report this to the appropriate agency.
Judicial/Administrative Proceedings: I may disclose PHI in response to a court order, a legally issued subpoena, or other administrative demands, but only to the extent required by the order or subpoena. In California, mental health records receive heightened protection, and I will assert legal privilege (if applicable) before releasing any information without your authorization.
Health Oversight Activities: I may disclose PHI to a health oversight agency (such as the California Board of Behavioral Sciences - BBS) for legally authorized purposes, such as audits, investigations, inspections, and licensure.
Organ and Tissue Donation: I may disclose PHI to organizations that handle organ procurement, tissue donation, or transplanting, but only as required to facilitate organ or tissue donation by a deceased patient.
Workers' Compensation: I may disclose PHI to the extent authorized by and necessary to comply with laws relating to Workers’ Compensation or other similar programs.
Prohibited Disclosures (Reproductive Healthcare): I am legally prohibited from disclosing your PHI for the purpose of investigating or imposing civil, criminal, or administrative liability on you (or any other person) for seeking, obtaining, providing, or facilitating lawful reproductive health care services.

IV. Uses and Disclosures Requiring Your Written Authorization

In all other situations, I will not use or disclose your PHI without your specific written Authorization.

Psychotherapy Notes: Psychotherapy Notes are separately maintained notes documenting the contents of conversation during a private counseling session. Most uses or disclosures of Psychotherapy Notes require your written Authorization, except in rare circumstances (such as for my defense in a legal action brought by you, or for government oversight of the originator).
Marketing & Sale of PHI: I must obtain your specific written Authorization prior to using or disclosing your PHI for marketing purposes or for any disclosure that constitutes a sale of PHI.
Disclosures to Family/Friends: While federal law (HIPAA) permits disclosure to family and friends involved in your care unless you object, California law (CMIA) provides greater protection. I will generally require your written Authorization or explicit permission before disclosing PHI to family members, friends, or other persons involved in your care or payment for care, except in emergencies or when required by law.

You may revoke any written Authorization at any time by submitting a written request to the Privacy Contact listed in Section VI. The revocation will not apply to any uses or disclosures already made in reliance on your original Authorization.

V. Your Rights Regarding Your PHI

You have the following rights regarding the PHI I maintain about you.

Right to Inspect and Copy: You have the right to inspect and obtain a copy of the PHI in your clinical and billing records. I may charge a reasonable, cost-based fee for the copying. I must respond to your written request within 15 days (in California, though HIPAA allows 30 days). I may deny your request in certain limited circumstances, which I will explain to you in writing.
Right to Request an Amendment: If you feel the PHI I have about you is incorrect or incomplete, you may ask me to amend the information. I will respond to your request within 60 days. If I deny your request, I will provide you with a written denial, and you have the right to submit a statement of disagreement, which I will file with your records.
Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures I have made of your PHI for the past six (6) years, excluding disclosures for TPO or those made with your Authorization.
Right to Request Restrictions: You have the right to request a restriction or limitation on the PHI I use or disclose about you for TPO. I am generally not required to agree to your request, but if I do, I am bound by that agreement unless in an emergency.
- Right to Restrict Disclosures to Health Plans for Out-of-Pocket Payment: You have the right to request that I restrict disclosure of your PHI to a health plan if the disclosure is for payment or health care operations and pertains solely to a health care item or service for which you have paid out-of-pocket in full. I must agree to this restriction, unless disclosure is required by law.
Right to Request Confidential Communications: You have the right to request that I communicate with you about health matters in a certain way or at a certain location. For example, you can ask that I only call your cell phone or send mail to a different address. I will accommodate all reasonable requests.
Right to a Paper Copy of this Notice: You have the right to a paper copy of this Notice, even if you have previously agreed to receive it electronically.

VI. Complaints and Contact Information

If you believe your privacy rights have been violated, you may file a complaint with me or with the federal government.

To file a complaint with the Provider: You may submit a written complaint to the Privacy Contact below. Filing a complaint will not result in retaliation or penalty.
Privacy Contact:

Name: Elizabeth Ngoc Nguyen, LMFT

Title: Practice Owner & Privacy Officer

Address: 10265 Rockingham Dr Ste 100 PMB 6065, Sacramento, CA 95827-2566

Phone: (657) 233-1833 Email: elizabeth.nguyen@fruiteatherapy.com

To file a complaint with the U.S. Government: You may send a written complaint to the U.S. Department of Health and Human Services, Office for Civil Rights (OCR).
To file a complaint with the California Licensing Board: You may also file a complaint against the provider with the state licensing board:

Board of Behavioral Sciences (BBS) 1625 N. Market Blvd., Suite S-200 Sacramento, CA 95834

Phone: (916) 574-7830 Website: https://www.bbs.ca.gov/

Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019 HHS-OCR Complaint Website

By agreeing to this form, you are acknowledging that you have received a copy of this HIPAA Notice of Privacy Practices.

Fruitea Therapy | Notice of Privacy Practices