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
are required by applicable federal and state law to maintain
the privacy of your health information. We are also required
to give you this Notice about our privacy practices, legal
obligations, and your rights concerning your health information
("Protected Health Information" or "PHI").
We must follow the privacy practices that are described
in this Notice (which may be amended from time to time).
more information about our privacy practices, or for additional
copies of this Notice, please contact us using the information
listed at the end of this Notice.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
A. Permissible Uses and Disclosures Without Your Written
We may use and disclose PHI without your written authorization,
excluding Psychotherapy Notes as described in Section
2, for certain purposes as described below. The examples
provided in each category are not meant to be exhaustive,
but instead are meant to describe the types of uses and
disclosures that are permissible under federal and state
1. Treatment: We may use and disclose PHI in
order to provide treatment to you. For example, we may
use PHI to diagnose and provide counseling service to
you. In addition, we may disclose PHI to other health
care providers involved in your treatment.
2. Payment: We may use or disclose
PHI so that services you receive are appropriately billed
to, and payment is collected from, your health plan.
By way of example, we may disclose PHI to permit your
health plan to take certain actions before it approves
or pays for treatment services.
3. Health Care Operations: We may use
and disclose PHI in connection with our health care
operations, including quality improvement activities,
training programs, accreditation, certification, licensing
or credentialing activities.
4. Required or Permitted by Law: We
may use or disclose PHI when we are required or permitted
to do so by law. For example, we may disclose PHI to
appropriate authorities if we reasonably believe that
you are a possible victim of abuse, neglect, or domestic
violence or the possible victim of other crimes. In
addition we may disclose PHI to the extent necessary
to avert a serious threat to your health or safety or
the health or safety of others. Other disclosures permitted
or required by law include the following: disclosures
for public health activities; health oversight activities
including disclosures to state or federal agencies authorized
to access PHI; disclosures to judicial and law enforcement
officials in response to a court order or other lawful
process; disclosures for research when approved by an
institutional review board; and disclosures to military
or national security agencies, coroners, medical examiners,
and correctional institutions as otherwise authorized
Uses and Disclosures Requiring Your Written Authorization
1. Psychotherapy Notes: Notes recorded by your
clinician documenting the contents of a counseling session
with you ("Psychotherapy Notes") will be used
only by your clinician and will not otherwise be used
or disclosed without your written authorization.
2. Marketing Communications: We will
not use your health information for marketing communications
without your written authorization.
3. Other Uses and Disclosures: Uses
and disclosures other than those described in Section
I.A. above will only be made with your written authorization.
For example, you will need to sign an authorization
form before we can send PHI to your life insurance company,
to a school, or to your attorney. You may revoke any
such authorization at any time.
YOUR INDIVIDUAL RIGHTS
A. Right to Inspect and Copy: You may request
access to your medical record and billing records maintained
by us in order to inspect and request copies of the records.
All requests for access must be made in writing. Under
limited circumstances, we may deny access to your records.
We may charge a fee for the costs of copying and sending
you any records requested. If you are a parent or legal
guardian of a minor, please note that certain portions
of the minor's medical record may not be accessible to
B. Right to Alternative Communications:
You may request, and we will accommodate, any reasonable
written request for you to receive PHI by alternative
means of communication or at alternative locations.
C. Right to Request Restrictions: You
have the right to request a restriction on PHI we use
for disclosure for treatment, payment or health care operations.
You must request any such restriction in writing addressed
to the Privacy Officer as indicated below. We are not
required to agree to any such restriction you may request.
D. Right to Accounting of Disclosures:
Upon written request, you may obtain an accounting of
certain disclosures of PHI made by us after April 14,
2003. This right applies to disclosures for purposes other
than treatment, payment or health care operations, excludes
disclosures made to you or disclosures otherwise authorized
by you, and is subject to other restrictions and limitations.
E. Right to Request Amendment: You have
the right to request that we amend your health information.
Your request must be in writing, and it must explain why
the information should be amended. We may deny your request
under certain circumstances.
F. Right to Obtain Notice: You have the right to obtain
a paper copy of this Notice by submitting a request to
our Privacy Officer at any time.
G. Questions and Complaints: If you desire
further information about your privacy rights, are concerned
that we have violated your privacy rights or if you object
to a decision we made about access to your PHI, you may
contact our Privacy Officer Diana Griffin at (707) 224-8266,
PO Box 841, Napa, CA 94559. You may also file written
complaints with the Director, Office for Civil Rights
of the U.S. Department of Health and Human Services, 200
Independence Avenue SW, Washington, DC 20201. We will
not retaliate against you if you file a complaint with
the Director or Aldea Children and Family Services.
EFFECTIVE DATE AND CHANGES TO THIS NOTICE
A. Effective Date: This Notice is effective on
April 14, 2003.
B. Changes to this Notice: We may change
the terms of this Notice at any time. If we change this
Notice, we may make the new Notice terms effective for
all PHI that we maintain, including any information created
or received prior to issuing the new Notice. If we change
this Notice, we will post the revised Notice in the waiting
area of our offices. You may also obtain any revised Notice
by contacting the Privacy Officer.