Notice of Psychologists Policies and Practices to Protect the Privacy of Your Health Information

I. This notice describes how psychological and medical information about you may be used and
disclosed and how you can get access to this information. Please review it carefully.

II. It is my legal duty to safeguard your Protected Health information (PHI).

By law I am required to insure that your PHI is kept private. PHI constitutes information created or
noted by me that can be used to identify you. It contains data about your past, present, or future
health or condition, the provision of health care services to you, or the payment for such health care.
I am required to provide you with this Notice about my legal duties and privacy procedures. This
Notice must explain when, why, and how I would use and/or disclose your PHI. Use of PHI means
when I share, apply, utilize, examine, or analyze information within my practice; PHI is disclosed
when I release, transfer, give, or otherwise reveal it to a third party outside my practice.
Authorization means your written permission for specific uses or disclosures. With some
exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose
for which the use or disclosure is made; however, I am always legally required to follow the privacy
practices described in this Notice.

Please note that I reserve the right to change the terms of this Notice and my privacy policies at any
time as permitted by law. Any changes will apply to PHI already on file with me. Before I make any
important changes to my policies, I will immediately change this Notice and give you a new copy and
post it on my website. You may also request a copy of this Notice from me, or you can view a copy
of it on my website, which is located at (www.mountainviewcounseling.com).

III. Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for certain treatment, payment, and
health care operations purposes without your authorization. In certain circumstances I can only do so
when the person or business requesting your PHI gives me a written request that includes certain
promises regarding protecting the confidentiality of your PHI. To clarify these terms, here are some
definitions:

Treatment is when I provide or another healthcare provider diagnoses or treats you. An

example of treatment would be when I consult with another health care provider, such as your
family physician or another psychologist, regarding your treatment
Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I
disclose your PHI to your health insurer to obtain reimbursement for your health care or to
determine eligibility or coverage. I could also provide your PHI to business associates, such as
billing companies, claims processing companies, and others that process health care claims for
my office.
Health Care Operations is when I disclose your PHI to facilitate the efficient and correct
operation of my practice. Examples: Quality control - I might use your PHI in the evaluation of
the quality of health care services that you have received or to evaluate the performance of the
health care professionals who provided you with these services. I may also provide your PHI to
my attorneys, accountants, consultants, and others to make sure that I am in compliance with
applicable laws.

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IV. Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

If disclosure is mandated by the California Child Abuse and Neglect Reporting law. For
example, if I have a reasonable suspicion of child abuse or neglect.
If disclosure is mandated by the California Elder/Dependent Adult Abuse Reporting
law. For example, if I have a reasonable suspicion of elder abuse or dependent adult abuse.
Health Oversight: If a complaint is filed against me with the California Board of Psychology,
the Board has the authority to subpoena confidential mental health information from me
relevant to that complaint.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a
request is made about the professional services that I have provided you, I must not release your
information without 1) your written authorization or the authorization of your attorney or
personal representative; 2) a court order; or 3) a subpoena duces tecum (a subpoena to produce
records) where the party seeking your records provides me with a showing that you have not
notified me that you are bringing a motion in the court to quash (block) or modify the subpoena.
The privilege does not apply when you are being evaluated for a third party or where the
evaluation is court ordered. I will inform you in advance if this is the case.
Serious Threat to Health or Safety: If you or your family member communicate to me that
you pose a serious threat of physical violence against an identifiable victim, I must make
reasonable efforts to communicate that information to the potential victim and the police. If I
have reasonable cause to believe that you are in such a condition, as to be dangerous to yourself
or others, I may release relevant information as necessary to prevent the threatened danger.
Workers Compensation: If you file a workers compensation claim, I may disclose to your
employer your medical information created as a result of employment-related health care services
provided to you at the specific prior written consent and expense of your employer so long as
the requested information is relevant to your claim provided that is only used or disclosed in
connection with your claim and describes your functional limitations provided that no statement
of medical cause is included.

V. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and health care operations
when your appropriate authorization is obtained. In those instances when I am asked for information
for purposes outside of treatment and payment operations, I will obtain an authorization from you
before releasing this information. I will also need to obtain an authorization before releasing your
psychotherapy notes. Psychotherapy notes are notes I have made about our conversation during a
private, group, joint, or family counseling session, which I have kept separate from the rest of your
medical record. These notes are given a greater degree of protection than PHI.
You may revoke or modify all such authorizations (or PHI or psychotherapy notes) at any time;
however, the revocation or modification is not effective until I receive it.

VI. Patients Rights

The Right to See and Get Copies of Your PHI. In general, you have the right to inspect or
obtain a copy (or both) of PHI and/or psychotherapy notes in my mental health and billing
records for as long as the PHI is maintained in the record. Your request to inspect or obtain a

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copy of your records should be make in writing and you will receive a response from me within
30 days of my receiving your written request. Under certain circumstances, I may deny your
request but in some cases you may have this decision reviewed. On your request, I will discuss
with you the details of the request and the denial process.
The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to
ask that I limit how I use and disclose your PHI. While I will consider your request, I am not
legally bound to agree. If I do agree to your request, I will put those limits in writing and abide by
them except in emergency situations.
The Right to Choose How I Send Your PHI to You. It is your right to ask that your PHI be
sent to you at an alternate address (for example, sending information to your work address rather
than your home address) or by an alternate method (for example, via email instead of by regular
mail). I am obliged to agree to your request providing that I can give you the PHI, in the format
you requested, without undue inconvenience.
The Right to Get a List of the Disclosures I Have Made. You generally have the right to
receive an accounting of disclosures of PHI for which you have neither provided consent nor
authorization (as described in Section IV of this notice). I will respond to your request for an
accounting of disclosures within 60 days of receiving your request. The list I give you will include
disclosures made in the previous six years unless you indicate a shorter period. The list will
include the date of the disclosure, to whom PHI was disclosed (including their address, if
known), a description of the information disclosed, and the reason for the disclosure.
The Right to Amend Your PHI. If you believe that there is some error in your PHI or that
important information has been omitted, it is your right to request that I correct the existing
information or add the missing information. Your request and the reason for the request must be
made in writing. You will receive a response within 60 days of my receipt of your request. I may
deny your request, in writing, if I find that: the PHI is (a) correct and complete, (b) forbidden to
be disclosed, (c) not part of my records, or (d) written by someone other than me. My denial
must be in writing and must state the reasons for the denial. It must also explain your right to file
a written statement objecting to the denial. If you do not file a written objection, you still have
the right to ask that your request and my denial be attached to any future disclosures of your
PHI. If I approve your request, I will make the change(s) to your PHI. Additionally, I will tell
you that the changes have been made, and I will advise all others who need to know about the
change(s) to your PHI.
The Right to Get This Notice by Email. You have the right to get this notice by email. You
have the right to request a paper copy of it, as well.

VII. Questions and Complaints

If you have questions about this notice, disagree with a decision I have made about access to your
records, or have other concerns about your privacy rights, you may contact me. If you believe that
your privacy rights have been violated and wish to file a complaint with me, you may send your
written complaint to me (Magdalene Holtam PhD, 2660 Solace Place Suite A Mountain View,
California 94040). You may also send a written complaint to the Secretary of the Department of
Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If you file a
complaint about my privacy practices, I will take no retaliatory action against you.

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VII. Notification of Breaches

In the case of a breach, Magdalene Holtam PhD is required to notify each affected individual whose
unsecured PHI has been compromised. Even if such a breach was caused by a business associate,
Magdalene Holtam PhD is ultimately responsible for providing the notification directly or via the
business associate. Magdalene Holtam PhD bears the ultimate burden of proof to demonstrate that
all notifications were given or that the impermissible use or disclosure of PHI did not constitute a
breach and must maintain supporting documentation, including documentation pertaining to the risk
assessment.
VIII. Individuals Right to Restrict Disclosures; Right of Access
To implement the 2013 HITECH Act, the Privacy Rule is amended, Magdalene Holtam PhD is
required to restrict the disclosure of PHI about you, the patient, to a health plan, upon request, if the
disclosure is for the purpose of carrying out payment or healthcare operations and is not otherwise
required by law. The PHI must pertain solely to a healthcare item or service for which you have paid
the covered entity in full.
The 2013 Amendments also adopt the proposal in the interim rule requiring Magdalene Holtam
PhD, to provide you, the patient, a copy of PHI to any individual patient requesting it in electronic
form. The electronic format must be provided to you if it is readily producible. OCR clarifies that
Magdalene Holtam PhD must provide you only with an electronic copy of their PHI, not direct
access to their electronic health record systems. The 2013 Amendments also give you the right to
direct Magdalene Holtam PhD to transmit an electronic copy of PHI to an entity or person
designated by you. Furthermore, the amendments restrict the fees that Magdalene Holtam PhD may
charge you for handling and reproduction of PHI, which must be reasonable, cost-based and identify
separately the labor for copying PHI (if any).
IX. Effective Date of This Notice
This notice went into effect on December 20, 2013

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