This Notice describes how information about you may be used and disclosed and how you can get
access to this information. Please review it carefully.
As a client of the independent practitioners of Associated Therapists, Inc., you are entitled to receive notice
about our privacy practices and how they may use and disclose your personal health information in different
circumstances. This Notice explains how they may use and disclose your personal health information, the choices and
rights you have about how your personal health information may be used and disclosed, and our obligations to
protect the privacy of your personal health information.
Associated Therapists, Inc. and its employees provide administrative support such as client and insurance
billing, office space, clerical services, and voice messaging to the professional staff. Associated Therapists,
Inc. and its employees do not engage in professional mental health practice. Each physician, nurse or therapist is
an independent individual performing their professional service in a private practice as governed and licensed by
the State of California.
When you become a client of the independent practitioners of
Associated Therapists, Inc., you provide them with information about your health. Each time you visit them, another
record of your visit and what was done is made. Your health record is the information that they use to plan your
care, provide treatment and receive payment for their services.
It is important for you to understand that your health record contains personal health information that is
protected by federal and state laws.
The independent practitioners of Associated Therapists, Inc.
are required to maintain the privacy of your personal health information and to provide you with a notice about
their legal duties and privacy practices with respect to your personal health information.
They are also required to accommodate reasonable requests that you make to
communicate personal health information by alternative means or at alternative
locations. Any time they use or disclose your personal health information, they
must follow the terms of this Notice.
Use And Disclosure Your Protected Health Information
A. Uses and Disclosures for Treatment,
Payment and Health Care Operations.
After making a good faith effort to provide you with this Notice, they may use your personal health
information to provide your treatment, to obtain payment for
your treatment and for their internal health care operations. They may use and
disclose your personal health information for such purposes in the following
(1) For Treatment. They may use and disclose your personal health information to
plan, provide and coordinate your health care services. For example if you are requiring medication as well as
therapy, both the therapist you see and the nurse practitioner or physician need to have your health
(2) For Payment. They may use and disclose your personal health information to
obtain payment for health care services they have provided to you. For example, they may need to give your health
insurance plan information about your treatment so that your health plan will pay them or repay you for the
services you received. They may also tell your health plan about a treatment you are going to receive or have
received to get approval or to determine if your plan will pay for the treatment.
(3) For Health Care Operations. They may use or disclose your protected health
information for their health care operations. For example, they may use or disclose
your personal health information to perform risk assessments and other
administrative tasks to monitor the quality of care that they provide.
B. Uses and Disclosures With Authorization.
For uses and disclosures of your personal health information not involving treatment, payment or health
care operations, they will receive your written authorization prior to
using or disclosing any personal health information (unless they are required or
permitted by law to use or disclose your information as set forth below). You
have the right to revoke any authorization previously granted. If you have any
questions about written authorizations, please contact our contact person at
(714) 898-0362 Extension 85, who will provide you with the information you need to revoke your
C. Uses and Disclosures Without Authorization.
They may use and disclose your personal health information without obtaining your consent or authorization, in
the following situations:
(1) Business Associates. There are some services that they provide through
contracts with our business associates. In such situations, they may disclose
your personal health information to our business associates so they can perform
the job they asked them to do. They require all business associates to
appropriately safeguard your information, in accordance with applicable law.
(2) Notification of Family or Close Friends. They may use or disclose your
personal health information to notify a family member, personal representative
or another person responsible for your care, provided you have the opportunity
to agree or object to the disclosure. If you are unable to agree or object, they
may disclose this information as necessary if they determine that it is in your
best interest based upon their professional judgment. In all cases, they will only
disclose the health information that is directly relevant to that person(s)
involvement with your health care.
(3) Required by Law. They may use or disclose your personal health information
to the extent that they are required by law to do so. The use or disclosure will be made in full compliance with
the applicable law governing the disclosure.
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed
without written permission.
Suspected child abuse or
dependant adult or elder abuse, for which we are required by law to report this to the appropriate authorities
If a client is threatening serious bodily harm to another person/s, we must notify the police and inform the
If a client intends to harm himself or herself, we will make every effort to enlist their cooperation in insuring
their safety. If they do not cooperate, we will take further measures without their permission that are provided by
law in order to ensure their safety.
(4) Public Health Activities. They may disclose your personal health information
for public health activities to a public health authority authorized by law to
collect or receive information for the purpose of controlling disease, injury or
disability. They may also disclose your health information to a public authority
authorized to receive reports of child abuse or neglect or to report information
about products or services under the jurisdiction of the United States Food and
Drug Administration. Additionally, they may disclose your health information to a
person who may have been exposed to a communicable disease or otherwise be at
risk of contacting or spreading a disease and to your employer for certain
work-related illness or injuries.
(5) Health Oversight Activities. They may make disclosures of your personal health
information to a health oversight agency charged with overseeing the health care industry. Disclosures will be made
only for activities authorized by law.
(6) Judicial and Administrative Proceedings. They may disclose your personal
health information in the course of any judicial or administrative hearing in
response to an order of a court or administrative tribunal, or in response to a
subpoena, discovery request or other lawful process where they receive
satisfactory assurance that appropriate precautions have been taken. In all
cases, they will take reasonable steps to protect the confidentiality of your
(7) Law Enforcement. They may disclose your personal health information for a law
enforcement purpose to law enforcement officials in compliance with and as
limited by applicable law.
(8) Marketing. For market activities, they will obtain your written authorization
prior to sending any information to you, unless they are not required by law to do
(9) Research. They may use or disclose your personal health information without
your authorization for research purposes when such research has been approved by an institutional review board that
has reviewed the research to ensure
the privacy of your personal health information, or as otherwise allowed by law.
(10) Victims of Abuse, Neglect or Domestic Violence. They may disclose personal
health information about an individual whom they reasonably believe to be a victim
of abuse, neglect or domestic violence to a government authority, including a
social service or protective service agency authorized by law to receive reports
of child abuse, neglect or domestic violence. Any such disclosures will be made
in accordance with and limited to the requirements of the law.
(11) Limited Government Functions. They may disclose your personal health
information to certain government agencies charged with special government
functions, as limited by applicable law. For example, they may disclose your
health information to authorized federal officials for the conduct of national
security activities, as required by law.
(12) Coroners, Medical Examiners and Funeral Directors. They may disclose personal
health information to a coroner or medical examiner to identify a deceased
person, determine a cause of death or for other duties as authorized by law. They
may also disclose personal health information to funeral directors in accordance
with applicable laws.
(13) Health and Safety. They may disclose your personal health information to
prevent or lessen a serious threat to a person(s) or the public(s) health and
safety. In all cases, disclosures will only be made in accordance with
applicable law and standards of ethical conduct.
(14) Workers Compensation. They may disclose your personal health information
in accordance with workers compensation laws.
Your Individual Rights
You have the right to do the following:
1. Right to Receive a Copy of this Notice. Upon request, you
have the right to receive a paper copy of this Notice. Please request this form from any Associated Therapist, Inc.
employee or professional staff member.
2. Right to Receive Further Information. You have the right to contact their contact person at (714) 898-0362
Extension 85 if you want additional information about their privacy practices, your privacy rights, or disagree
about a decision they made about your personal health information, or if you believe that your privacy rights have
been violated. The contact person will provide you with the information you need to file a complaint.
3. Right to Inspect and Copy Your Health Information. Upon written request, you have the right to access
and obtain a copy of your health information maintained by them. Please contact the Privacy Officer at (714)
898-0362 Extension 85 or firstname.lastname@example.org for information you need to access
and copy your protected health information.
4. Right to Amend Your Health Information. You have the right to request in writing that they amend health
information maintained in your health record. They will comply with your request in the event that they determine
the information that would be amended is false, inaccurate or misleading. Please contact the Privacy Officer at
(714) 898-0362 Extension 85 or email@example.com for information you need to request
an amendment of your personal health information.
5. Right to Request Additional Restrictions on Uses and Disclosures of Your Health Information. You have
the right to request in writing that they place additional restrictions on how they use or disclosure your personal
health information. While they will consider any request for additional restrictions, they are not required to
agree to your request. Please contact the Privacy Officer at (714) 898-0362 Extension 85 or firstname.lastname@example.org for information you need to request
additional restrictions on how they may use and disclose your personal health information.
6. Right to Request an Accounting of Disclosures. You have a
right to request in writing an accounting of certain disclosures made by them of
your personal health information. For each disclosure, the accounting will
include the date the information was disclosed, to whom, the address of the
person or entity that received the disclosure (if known), and a brief statement
of the reason for the disclosure. Please contact the Privacy Officer at
(714) 898-0362 Extension 85 or email@example.com for information you
need to request an accounting of disclosures.
7. Right to Request Confidentiality in Certain Communications.
You have the right to request to receive your health information by alternative
means of communication or at alternative locations. They will accommodate any
such reasonable written request made on your behalf. Please contact the Privacy
Officer at (714) 898-0362 Extension 85 or firstname.lastname@example.org for
information you need to request confidentiality in certain communications.
8. Right to File a Complaint. If you believe your privacy rights have been violated, in addition to filing
a complaint with them, you have the right to file a written complaint with the Office of Civil Rights of the United
States Department of Health and Human Services. Upon request, the Privacy Officer will provide with the information
needed to file your complaint. Under no circumstances will they retaliate against you for filing a complaint with
us or the Office of Civil Rights.
Changes to Notice
They reserve the right to change their privacy practices and
alter this Notice according to those changes. In the event that their Notice
changes, they will mail you a copy of our revised notice to the address you have
To contact our Privacy Officer, please contact Patricia Taylor,
Associated Therapists, Inc. at (714) 898-0362 Extension 85, or email email@example.com
Effective Date of this Notice
This Notice is currently in effect and will remain in
effect until further notice.
Page Last Updated: 08/27/11