Notice of Privacy Practices

Pacific Emotional Wellness, Camille Johnson, LMFT 81572 and LMFT/LCSW or Registered Associate MFT in this practice, 441 Marsh St San Luis Obispo, CA 93401, p: (805) 234-8007

I. MY PLEDGE REGARDING HEALTH INFORMATION

I understand that your health information is personal and I am committed to protecting it. I create a record of the care and services you receive from me. This notice describes how I may use and disclose this information and your rights regarding it.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

I may use and disclose your information for treatment, payment, or healthcare operations. This may include sharing your information with other healthcare providers involved in your care.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

  • Psychotherapy Notes: I require your written authorization to use or disclose your psychotherapy notes, except in specific situations outlined in the law.
  • Marketing Purposes: I will not use your information for marketing purposes.
  • Sale of PHI: I will not sell your protected health information (PHI).

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION

In certain situations, I may use or disclose your information without your authorization, such as:

  • Required by law
  • Public health activities
  • Health oversight activities
  • Judicial and administrative proceedings
  • Law enforcement purposes
  • Coroners or medical examiners
  • Research purposes
  • Specialized government functions
  • Workers' compensation purposes
  • Appointment reminders and health-related benefits or services

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT

I may disclose your information to a family member, friend, or other person involved in your care or payment for your care, unless you object.

VI. YOUR RIGHTS WITH RESPECT TO YOUR PHI

You have the following rights:

  1. Request Limits on Uses and Disclosures: You can request that I not use or disclose your information for certain purposes.
  2. Request Restrictions for Out-of-Pocket Expenses: You can request restrictions on disclosures to health plans for payment if you paid for the service in full.
  3. Choose How I Send PHI to You: You can request to receive information in a specific way (e.g., home or office phone).
  4. See and Get Copies of Your PHI: You have the right to get a copy of your medical record and other information I have about you.
  5. Get a List of Disclosures I Have Made: You can request a list of disclosures I have made of your information.
  6. Correct or Update Your PHI: You can request that I correct or update your information.
  7. Get a Paper or Electronic Copy of this Notice: You have the right to get a paper or electronic copy of this notice.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on September 20, 2013.