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NOTICE OF PRIVACY PRACTICES

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.

If you have any questions about this notice, please contact Azarm Ghareman, PhD (see bottom of this form.)

WHO WILL FOLLOW THIS NOTICE
This notice describes my privacy practices and those of my staff. I may share information about you with my staff as necessary to provide services to you and for treatment, payment or health care operations purposes described in this notice.

MY PLEDGE REGARDING MEDICAL INFORMATION
I understand that medical and mental health information about you is personal. I am committed to protecting medical information about you. I will create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by me, or that I have received from other health care providers about you. Your personal doctor and the health care facility where you reside may have different policies or notices regarding their use and disclosure of your medical information created by them.
This notice will tell you about the ways in which I may use and disclose medical information about you. It also describes your rights and certain obligations I have regarding the use and disclosure of medical information.
I am required by law to:

  • Make sure that medical information that identifies you is kept private (with certain exceptions);
  • Give you this notice of my legal duties and privacy practices with respect to medical information about you; and
  • Follow the terms of the notice that is currently in effect.

HOW I MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that I may use and disclose medical information. For each category of uses or disclosure I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

DISCLOSURES AT YOUR REQUEST
I may disclose information when requested by you. This disclosure at your request may require a written authorization by you.

FOR TREATMENT
I may use medical information about you to provide you with medical treatment or services. I may disclose medical information about you to doctors, nurses, technicians, health care students, or other healthcare personnel who are involved in taking care of you. For example, a doctor treating you for breathing problems may need to know that a medication that has been prescribed has caused you to feel anxious or have difficult sleeping.

FOR PAYMENT
I may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, I may need to give your health plan information about care I have provided to you so your health plan will pay me or reimburse me for the services. I may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

FOR HEALTH CARE OPERATIONS
I may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to assure you receive quality care. For example, I may use medical information to review my treatment and services and to evaluate the performance of my office in meeting your needs. I may also use your information in the following ways:

Appointment Reminders
I may use and disclose medical information to contact you as a reminder that you have an appointment for treatment.
Treatment Alternatives
I may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Products and Services
I may use and disclose medical information to tell you about our health-related products or services that may be of interest to you.

AS REQUIRED BY LAW
I will disclose medical information about you when required to do so by federal, state or local law.

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY
I may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS

PUBLIC HEALTH ACTIVITIES
I may disclose medical information about you for public health activities. These activities generally include the following:

  • To prevent or control disease, injury or disability;
  • To report regarding the abuse or neglect of children, elders and dependent adults;
  • To report reactions to medications or problems with products;
  • To notify people of recalls of products they may be using;
  • To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law;
  • To notify emergency response employees regarding possible exposure to HIV/AIDS, to the extent necessary to comply with state and federal laws.

HEALTH OVERSIGHT ACTIVITIES
I may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

LAWSUITS AND DISPUTES
If you are involved in a lawsuit or a dispute, I may disclose medical information about you in response to a court or administrative order. I may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.

LAW ENFORCEMENT
I may release medical information if asked to do so by a law enforcement official:

  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
  • About a death we believe may be the result of a criminal conduct;
  • About criminal conduct where you receive services; and
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
I may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. I may also release medical information about a patient to funeral directors as necessary to carry out their duties.

NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES
I may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS
I may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or conduct special investigations.

SPECIAL CATEGORIES OF INFORMATION
In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosure described in this notice. For example, there are special restrictions on the use or disclosure of certain categories of information, for example, tests for HIV or treatment for mental health conditions or alcohol and drug abuse. Government health benefit programs, such as Medicaid, may also limit the disclosure of beneficiary information for purposes unrelated to the program.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information I maintain about you.

RIGHT TO INSPECT AND COPY
You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to:
Azarm Ghareman, PhD
Clinical Psychologist, PSY17003
Mailing Address:
1241 Johnson Avenue, PMB 118
San Luis Obispo, CA 93401-3306
Phone: (805) 546-1190

If you request a copy of the information, I may charge a fee for the costs of copying, mailing or other supplies associated with your request.
I may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional will review your request and the denial. I will comply with the outcome of the review.

RIGHT TO AMEND
If you feel that medical information we have about you is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment for as long as the information is kept by or for me.

To request an amendment, your request must be made in writing and submitted to me at the above noted address. In addition, you must provide a reason that supports your request.

I may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, I may deny your request if you ask us to amend information that:

  • Was not created by me, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for me;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.

RIGHT TO AN ACCOUNTING OF DISCLOSURES
You have the right to request an “accounting of disclosures.” This is a list of the disclosures I have made of medical information about you other than my own uses for treatment, payment and health care operations (as those functions are described above), and with other exceptions pursuant to the law.

To request this list or accounting of disclosures, you must submit your request in writing to me at the above noted address. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, I may charge you for the costs of providing the list. I will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. If I maintain electronic health records about you, more information may be provided within a three-year window of time.

In addition, we will notify you as required by law if your health information is unlawfully accessed or disclosed.

RIGHT TO REQUEST RESTRICTIONS
You have the right to request a restriction or limitation on the medical information I use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.
If you pay for a treatment or procedure wholly out-of-pocket, you may request that I not disclose information about that particular treatment to your health plan; I am required to honor that request.

To request restrictions, you must make your request in writing to the above noted address; In your request, you must tell me 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; 3) to whom you want the limits to apply, for example, disclosures to your spouse.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS
You have the right to request that I communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that I only contact you by mail.

To request confidential communications, you must make your request in writing to me at the above noted address. I will not ask you the reason for your request. I will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

RIGHT TO A PAPER COPY OF THIS NOTICE
You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
You may also simply ask me for a paper copy of this notice.

CHANGES TO THIS NOTICE
I reserve the right to change this notice. I reserve the right to make the revised or changed notice effective for medical information I already have about you as well as any information I receive in the future. I will post a copy of the current notice on my website. The notice will contain the effective date on the first page, in the top right-hand corner.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the U.S. Department of Health and Human Services. You may also file a complaint with me at the following address:
Azarm Ghareman, PhD
Clinical Psychologist, PSY17003
Mailing Address:
1241 Johnson Avenue, PMB 1185

San Luis Obispo, CA 93401-3306
Phone: (805) 546-1190
All complaints must be submitted in writing.
You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to me will be made only with your written permission. If you provide me permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if I have already acted in reliance on your permission. You understand that I am unable to take back any disclosures I have already made with your permission, and that I am required to retain my records of the care that I provided to you.