525 N. Cabrillo Park Drive, Suite 300
Santa Ana, CA 92701
Telephone: (714) 953-4455
Contact Person: Tay Sandoz, Psy.D., Clinical Program Director
The effective date of this NOTICE is April 14, 2003. Revised May 2020
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. The privacy of your health information is important to Child Guidance Center, Inc.
Child Guidance Center, Inc. (CGC) is required by legal statute to protect the privacy of your health information. This “personal health information” is defined as that health information that can be used to identify you, has been created by CGC, or has been received from another office or entity. It applies to past, present and future health or condition, your treatment, payment for services, and other health practices which will be explained to you.
CGC has the duty to provide you with this NOTICE, which contains a description of how your health information will be used and disclosed for purposes of treatment, payment, and other health practices. The “use” of this information applies to the sharing, utilization, examination, or analysis of this information within this treatment facility. Your health information is “disclosed” when it is released or transferred out of this office to another party or entity. These practices will be explained to you in this NOTICE. CGC has the legal duty, with some exceptions, to disclose or use only the necessary information to accomplish the task at hand. Additionally, CGC is legally required to apply and follow the practices described in this NOTICE.
CGC has the right to change the privacy practices as describe in this NOTICE at any time, as permitted by law. The changes will apply to your health information held by this office. You will receive an updated copy of the NOTICE and it will be posted in this office. You can request a copy of this NOTICE at any time by notifying our CONTACT OFFICER at the address and telephone number located at the end of this NOTICE.
CGC is permitted to use and disclose your health information for the purposes of providing treatment, payment for services rendered, and healthcare operations. Some of these require your authorization and others do not.
Some examples that do not require your authorization include:
California law gives heightened protections to HIV/AIDS information. Generally, we must obtain your written authorization specifically permitting a disclosure of the results of an HIV/AIDS test for each separate disclosure made. We may disclose your HIV/AIDS test results without your authorization and as required under State reporting laws for purposes of public health investigation, control, or surveillance. Additionally, disclosures to a health care provider may be made without specific patient authorization for the direct purposes of diagnosis, care, or treatment of the patient. Your physician who orders an HIV test on your behalf may disclose the result of your HIV test to your health care providers for purposes related to your diagnosis, care, or treatment.
The confidentiality of your substance and alcohol use disorder records are protected by 42 USC 290dd-2 and the Department of Health and Human Services (HHS) regulations at 42 CFR Part 2 – Confidentiality of Substance Use Disorder Patient Records. Generally, we are not allowed to disclose your participation in the program or identify you as having an alcohol or drug abuse problem to an outside person unless:
(1) You consent in writing;
(2) The disclosure is to prevent multiple 42 CFR Part 2 program enrollments;
(3) The disclosure is allowed by a court order;
(4) The disclosure is made to medical personnel to the extent necessary to meet a bona fide medical emergency;
(5) The disclosure is for the purpose of conducting scientific research; or
(6) The disclosure is made for certain audit and/or evaluation purposes.
Federal law and regulations allow communication of personally identifying information about you by our program to law enforcement agencies or officials about a crime committed by you either at our program or against any person who works for the program premises or about any threat to commit such a crime. Federal laws and regulations allow our program to report under state law personally identifying information about you in connection with incidents of suspected child abuse or neglect to appropriate State or local authorities. If you believe that the privacy of your information protected by 42 USC 290dd-2 and 42 CFR Part 2 has been violated, you may contact the U.S. Attorney’s Office, Central District of California, Santa Ana Branch Office at 411 W. Fourth Street, Suite 8000, Santa Ana, CA 92701 or by phone at (855) 898-3957.
Access To Your Health Information: You have the right to examine or obtain copies of your health information, with some limited exceptions. CGC will attempt to comply with the requested format, unless we are unable to do so. The request must be made in writing and we will comply within 30 days of receiving your written request. You will be charged $0.25 per page. We may choose to provide you with a summary or synopsis of your health information if you agree. Should CGC deny your request, you will be provided a reason in writing and an explanation of your rights to initiate a review of the denial.
Requesting Limits on Uses and Disclosures of Your Health Information: You have the right to request limitation on the use and disclosure of your health information. CGC will review your request and may choose not to accept it, except to the extent that you request a restriction on disclosures to a health plan or insurer for payment or health care operations purposes and the items or services have been paid for out of pocket in full. If your request is accepted, a written format will be included in your records and this office will abide by the request. The request may not interfere with the legally defined uses and disclosures of your health information.
Receiving Health Information: You may request that health information be sent to you to a specific location and by specific means such as E-mail. CGC will attempt to comply as long as it is feasible.
Accounting for Disclosures: You have the right to request and receive a list of disclosures made on your behalf by CGC for reasons other than treatment, payment, or healthcare operations. The request is valid for the last six years from the date of your request. You may make one such request every year. The list will not include disclosures based on your written authorization; to receive payment for your treatment; to family members or friends involved in your treatment; or for reasons related to legal actions. There will be a reasonable charge for additional requests made in one 12-month period.
The Right to Amend Your Health Information: You have the right to request an amendment or correction to your health information. The request must be made in writing and a reason for your request must also be included. CGC must respond to your request within 60 days of the request. The request will be granted or denied. If your request is granted, the appropriate changes will be made, you will be informed of the changes made and third parties needing to know about the changes will be notified.
CGC can deny your request if the information is complete and correct, it was not created by CGC, not part of the office records, or cannot be disclosed. You will receive a written statement stating the reason for a denial. You will be provided with the format to file a written disagreement with the denial. You also have the right to request that your original request and our denial be attached to all future disclosures of your health information.Breach Notification: In the event of a breach of your unsecured protected health information, CGC will notify you of the circumstances of the breach. Electronic Notification: You have the right to receive this NOTICE by E-mail or in written format.
Should you require additional information, please contact Tay Sandoz, Psy.D. at: (714) 953-4455 ext 635
Should you believe that CGC has violated your privacy rights; you disagree with a decision made about access to your health information; you disagree with a response to your request to amend or restrict the use or disclosure of you health information; or disagree with our decision to contact you via a specific method or location, you may complain to our CONTACT OFFICER at (714) 953-4455 and/or submit a written complaint to the United States Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C., 20201. This office will not retaliate against you in any way should you choose to file a complaint.
Contact Officer: Tay Sandoz, Psy.D.
Telephone: (714) 953-4455 ext. 635
Fax: (714) 542-2793
525 N. Cabrillo Park Drive, Suite 300
Santa Ana, CA 92701
(This material is adapted from “HIPAA Made Easy: A Workbook for Mental Health Clinicians”. It is used with written permission from the author, Federico C. Grosso, PhDHIPAA Notice of Privacy Practices, Policy & Procedures, v.2