Notice of Privacy Practices

Effective: [PLACEHOLDER — effective date]

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.

Our Commitment to Your Privacy. Pacora is required by law to maintain the privacy of your Protected Health Information (PHI) under both the federal Health Insurance Portability and Accountability Act (“HIPAA”) and California's Confidentiality of Medical Information Act (CMIA). We are committed to protecting your health information.

Changes to the Terms of This Notice. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Your Health Information Rights

• Get an electronic or paper copy of your medical record. You can ask to see or get a copy of your medical record and other health information we have about you. We will provide a copy or summary, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
• Ask us to correct your medical record. You can ask us to correct health information you think is incorrect or incomplete. We may say “no,” but we'll tell you why in writing within 60 days.
• Request confidential communications. You can ask us to contact you in a specific way or to send mail to a different address. We will say “yes” to all reasonable requests.
• Ask us to limit what 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 if it would affect your care. If you pay out-of-pocket in full for a service, you can ask us not to share that information with your health insurer for payment or operations, and we will say “yes” unless a law requires us to share it.
• Get a list of those with whom we've shared information. You can ask for an accounting of disclosures for six years prior to the date you ask.
• Get a copy of this privacy notice. You can ask for a paper copy at any time.
• 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.

Your Choices

• 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; include your information in a hospital directory; or contact you for fundraising efforts.
• If you are not able to tell us your preference (for example if you are unconscious), we may share your information if we believe it is in your best interest, or 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: marketing purposes, sale of your information, or sharing of psychotherapy notes.
• In the case of fundraising, we may contact you, but you can tell us not to contact you again.

How We May Use and Disclose Your Health Information

• For Treatment, Payment, and Health Care Operations. We may use and disclose your PHI for your treatment, to obtain payment for services, and for our own healthcare operations, such as quality assessment and improvement.
• As Required By Law. We will disclose your PHI when required by federal or state law.
• Public Health Activities. For example, preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse or neglect, and reducing a serious threat to health or safety.
• Health Oversight Activities. For audits, investigations, inspections, and licensure as authorized by law, including with the Department of Health and Human Services.
• Organ and Tissue Donation, Lawsuits and Disputes, Law Enforcement, Coroners/Medical Examiners/Funeral Directors, Workers' Compensation, Special Government Functions, and National Security, as authorized by law.
• For Our Business Associates. We may disclose your health information to business associates that perform functions on our behalf, such as billing or technical services, under a written contract requiring them to protect your information.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing.

Uses and Disclosures Requiring Your Written Authorization

California's CMIA is generally stricter than HIPAA and often requires your specific written authorization before your information can be disclosed. Our policy is to follow the stricter law. We must obtain your written authorization for most uses and disclosures of psychotherapy notes, uses and disclosures for marketing, disclosures that constitute a sale of your PHI, and most disclosures for research. You may revoke an authorization at any time, in writing.

Special Protections under California Law

• Minors. In California, there are situations where minors can consent for their own treatment, and the parent or guardian may not have access to the minor's health record without the minor's written consent (for example, treatment for pregnancy, sexually transmitted diseases, drug or alcohol abuse, and when a minor is legally emancipated).
• Psychotherapy Notes & Substance Use Records. These records have special protections and generally require a specific written authorization before they can be disclosed.

Filing a Complaint

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint. To file a complaint with our practice, please contact: Pacora, Nicholas Schmidt, Privacy Officer, 1333 Camino del Rio S #103, San Diego, CA 92108, (858) 703-5643 / [EMAIL]. To file a complaint with the U.S. Department of Health and Human Services, contact the Office for Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201, 1-877-696-6775, www.hhs.gov/ocr/privacy/hipaa/complaints/.