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.
GROWURPOTENTIL (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.
To inspect and copy PHI.
You can ask for an electronic or paper copy of PHI. The Practice may respond with a summary letter, as is the legal right of a mental health care provider in California.
To amend PHI.
You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.
To request confidential communications.
You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.
To limit what is used or shared.
You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can expect that this Practice will not share PHI with any health insurer.
You can expect the Practice to decline to share your PHI with family members or friends who request information about you or your care.
To obtain a list of those with whom your PHI has been shared.
You can ask for a list of the times your health information has been shared, and you will be charged an admin fee for this list.
To receive a copy of this Notice.
You can ask for a PDF copy of this Notice, even if you agreed to receive the Notice electronically.
To choose someone to act for you.
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.
To file a complaint if you feel your rights are violated.
You can file a complaint by contacting the Practice by mail to: GROWURPOTENTIAL c/o MEISHA THRASHER, EXECUTIVE DIRECTOR 6535 WILSHIRE BLVD STE 130 LOS ANGELES CA 90048 or by email to: MEISHA@GROWURPOTENTIAL.ORG
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
The Practice will not retaliate against you for filing a complaint.
OUR USES AND DISCLOSURES
1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information to manage your care All Clinical Supervisors and Case Managers connected to your care may access your therapist’s notes and chart details including PHI. Your information is not trafficked outside of this HIPPA-compliant system. We do not bill insurance or send PHI data to insurance payers.
2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
• Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
• Serious threat to health or safety: To prevent a serious and imminent threat.
• Abuse or Neglect: To report abuse, neglect, or domestic violence.
• Judicial and administrative proceedings: To respond to a court orders.
3. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to disclose PHI for any purpose.
• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice reserves the right to amend the Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website [https://www.growurpotential.org/phi].
• The Practice will inform you if PHI is compromised in a breach.
This Notice is effective for one year from the date signed.
Consent form link
Client Information link
Client History form