Notice of Privacy Practice

ELIZABETH NGUYEN, LMFT 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.

I. My Pledge Regarding Your Health Information

I understand that health information about you and your mental health care is personal. I am committed to protecting your health information. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements.

This notice applies to all of the records of your care generated by Elizabeth N. Nguyen and my practice, Fruitea Therapy. This notice will tell you about the ways in which I may use and disclose your health information. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information

I am required by law to:

• Make sure that protected health information ("PHI") that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to your health information.

• Follow the terms of the notice that is currently in effect.

I reserve the right to change the terms of this Notice at any time. Any changes will apply to all of the health information I have about you. I will post a copy of the new Notice in my office and on my website. The new Notice will also be available upon request.

II. How I May Use and Disclose Your Health Information

The following categories describe different ways that I may use and disclose your health information.

For Treatment, Payment, or Health Care Operations: I may use or disclose your PHI for my own treatment, payment, or health care operations activities. For example:

• Treatment: I may share your information with a psychiatrist or other health care provider to coordinate your care, but only with your written authorization.

• Payment: I may use and disclose your PHI to bill and collect payment from you, your insurance company, or a third party. For example, I may need to tell your health plan about your diagnosis and the services I provided so that they will pay for your treatment.

• Health Care Operations: I may use and disclose your PHI for my practice operations. This may include conducting quality review, or for professional supervision and training.

Uses and Disclosures That Require Your Authorization: I must obtain your written authorization for the following:

• Psychotherapy Notes: I may keep "psychotherapy notes" as defined by HIPAA. With very limited exceptions (such as for my own use in treating you or to defend myself in a legal proceeding), any use or disclosure of these notes requires your specific, written authorization.

• Marketing Purposes: I will not use or disclose your PHI for marketing purposes without your written authorization.

• Sale of PHI: I will not sell your PHI without your written authorization.

Uses and Disclosures That Do Not Require Your Authorization: I may use and disclose your PHI without your authorization for the following reasons, subject to certain limitations in the law:

• When Required by Law: I may disclose your PHI when a state or federal law requires me to.

• For Public Health Activities: This includes reporting suspected child, elder, or dependent adult abuse or neglect, or when a serious threat to the health or safety of yourself or others is present.

• Health Oversight Activities: I may disclose your PHI to health oversight agencies for activities such as audits, investigations, and inspections.

• Judicial and Administrative Proceedings: I may disclose your PHI in response to a court or administrative order, although I will always try to obtain your written authorization first.

• Law Enforcement: I may disclose your PHI to law enforcement officials, for example, to report a crime that occurred on my premises.

• To Coroners and Medical Examiners: I may disclose your PHI to these individuals when they are performing duties authorized by law.

• For Workers’ Compensation: I may disclose your PHI to comply with workers’ compensation laws.

• Appointment Reminders: I may use and disclose your PHI to contact you with appointment reminders.

Disclosures to Family, Friends, or Others: I may disclose your PHI to a family member, friend, or other person you indicate is involved in your care or the payment for your health care. I will only do this if you do not object.

III. Your Rights Regarding Your Health Information

You have the following rights concerning your PHI:

• The Right to Inspect and Copy Your PHi: You have the right to request access to and a copy of your medical and billing records and other information I have about you. I may charge a reasonable, cost-based fee for this. I will provide a copy or a summary of your record within 30 days of receiving your written request.

• The Right to Request an Amendment: If you feel that the health information I have about you is incorrect or incomplete, you may ask me to amend it. I may deny your request, but I will tell you why in writing within 60 days.

• The Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures I have made of your PHI for purposes other than treatment, payment, or health care operations. I will provide one list per year at no charge.

• The Right to Request Restrictions: You have the right to request a restriction or limitation on the health information I use or disclose about you for treatment, payment, or health care operations. I am not required to agree to your request, but I will consider it carefully.

• The Right to Request Restrictions for Out-of-Pocket Payments: If you pay for an item or service in full out-of-pocket, you have the right to request that I not disclose that information to your health plan for payment or health care operations purposes.

• The 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 contact you at work or by mail to a specific address.

• The Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice, even if you have agreed to receive an electronic copy.

IV. Complaints

If you believe your privacy rights have been violated, you may file a complaint with me or with the Secretary of the Department of Health and Human Services. To file a complaint with me, please contact me at my information listed at the top of this notice. There will be no retaliation for filing a complaint.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. You will be sent a Notice of Privacy Practices form electronically and also have the right to request a paper copy. Please contact me via email to request a paper copy.

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