Notice of Privacy Practices for Bridge to Wellness Counseling
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NOTICE OF PRIVACY PRACTICES THIS NOTICE OF PRIVACY PRACTICES (“Notice”) DESCRIBES HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR PLEDGE REGARDING YOUR PROTECTED HEALTH INFORMATION Bridge to Wellness Counseling LCSW Inc. (“Bridge to Wellness”) is required by law to maintain the privacy and security of your protected health information (“PHI”) under the Health Insurance Portability and Accountability Act (“HIPAA”) and other applicable law. PHI is information about you, including basic demographic information, that may identify you and that relates to your past, present or future physical or mental health condition, treatment, or payment for health services. We must follow the duties and privacy practices described in this Notice and provide you with a copy of it upon your request. We will not use or share your information other than as described here unless you tell us we can in writing. You may change your mind at any time by informing us, in writing, that you have changed your mind. CHANGES TO THE TERMS OF THIS NOTICE Bridge to Wellness reserves the right to amend this Notice from time to time. The new Notice will be available upon request and on our website. USES AND DISCLOSURES OF YOUR HEALTH INFORMATION We may use or disclose your PHI for the following purposes: Treatment. We may use or disclose your PHI with other health professionals for purposes of providing treatment. For example, your therapist may disclosure your PHI to your primary health care practitioner or in consultations with another therapist to carry out the diagnosis and treatment of your mental health condition. Payment. We may use or disclose your PHI for purposes of billing and collecting payment for our services. Health Care Operations. We may use or disclose your PHI to run our practice, improve your care, and contact you when necessary. As Required by Law. We may share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. We may also share information about you to the extent we are required by law in response to a court or administrative order, or in response to a subpoena. Help with Public Health and Safety Issues. We can share health information about you for certain situations to the extent permitted by law such as reporting suspected abuse, neglect, or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety, including my own. Address Workers’ Compensation, Law Enforcement, and Other Government Requests. We can use or disclosure health information about you for workers’ compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; and for special government functions such as military, national security, and presidential protective services. Disclosures to Business Associates. We may disclose your PHI to certain of our service providers who contract with us and that may have access to certain of your PHI. Uses and disclosures of PHI for purposes other than those described above will not be made in the absence of a written authorization signed by you or your personal representative. Once you sign an authorization, you may revoke it by contacting us at any time unless it has already been relied upon to use or disclose PHI. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share
information with your family, close friends, or others involved in your care Share information in a disaster relief situation. Contact you for fundraising efforts If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases, we never share your information unless you give us written permission in accordance with applicable law: Marketing purposes. Sale of your information. Sharing of psychotherapy notes, except as described below. USE OF PSYCHOTHERAPY NOTES There are certain scenarios in which our ability to use and disclose your PHI is further restricted by applicable law. In such scenarios, we will comply with the more restrictive law. For example, our therapists may keep psychotherapy notes, as defined under HIPAA. Any use or disclosure of such notes specifically requires your written authorization unless the use or disclosure is: For use in treating you. For use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. For use in our defense in legal proceedings brought by you. For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA. Required by law and the use or disclosure is limited to the requirements of such law. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. Required by a coroner who is performing duties authorized by law. Required to help avert a serious threat to the imminent health and safety of others. YOUR RIGHTS WITH RESPECT TO YOUR PHI You have the following rights with respect to your PHI: Right to Receive an Electronic or Paper Copy of Your Client Record. You can ask to see or to receive an electronic or paper copy of your record and other health information we have about you. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Right to Ask Us to Correct Health Information About You. You can ask us to correct health information about you that you think is incorrect or incomplete. We may say “no” to your request, but we’ll tell you why in writing within 60 days. Right to Request Confidential Communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests. Right to Ask Us to Limit What Health Information We Use or Share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. Right to Receive a List of Those with Whom We’ve Shared Your Information. You can ask for a list of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one list a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Right to Receive a Copy of this Privacy Notice. You can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically. We will provide you with a paper copy promptly. Right to Choose Someone to Act on Your Behalf. If you have given someone power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. Right to File a Complaint if You feel Your Rights Have Been Violated. You can complain if you feel we have violated your rights by contacting us at 415-870-6494. In addition, you can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint. BREACH NOTIFICATION. Bridge to Wellness is required by law to notify you in the event that your PHI is subject to a security breach unless we reasonably determine, after fully investigating the situation and assessing the risk presented, that there is a low probability that the privacy or security of your PHI has been compromised. You will be notified without unreasonable delay and in no event later than sixty (60) days following my discovery of the security breach. Such notification will include information about the security breach, including steps that we have taken to mitigate potential harm, and a contact person to whom you may address additional questions. QUESTIONS, COMMENTS, OR COMPLAINTS If you have any questions or comments about this Notice, or if you have any complaints about our privacy practices, please contact us at 415-870-6494. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint. EFFECTIVE DATE OF THIS NOTICE This Notice went into effect on April 21, 2025 ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE Under HIPAA, you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of this Notice.