This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

I. Uses and Disclosures for Treatment, Payment and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes without your authorization. In certain circumstances I can only do so when the person or business requesting your PHI gives me a written request that includes certain promises regarding protecting the confidentiality of your PHI. To help clarify these terms, here are some definitions:

“PHI” refers to information in your health record that could identify you.

“Treatment” is when I provide, coordinate, or manage your health care and related services. This includes consultation about you with other health care providers (for example, your primary care physician, psychiatrist, or another mental health provider).

“Payment” refers to activities related to obtaining reimbursement for your health care services. Examples of these activities may include disclosing your PHI to your health insurance plan for determinations for eligibility or coverage, billing, payment, claims management, collection activities, records reviews, and utilization reviews.

“Health Care Operations” are activities that relate to the performance and operation of my practice. Examples of health care operations are the use of an electronic records management system, quality assessment and improvement activities, business-related matters such as audits and administrative services, case management, care coordination, appointment reminders, and to contact you as necessary.

“Use” applies only to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing PHI.

“Disclosure” applies to activities outside of my practice, such as releasing, sharing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment and health care operations when your appropriate authorization is obtained.

An “authorization” is written permission above and beyond the general consent. It permits only specific disclosures. In those instances, when I am asked for information for purposes outside of treatment, payment, and health care operations, I will obtain an authorization from you before releasing this information.

You may revoke or modify authorizations of PHI at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have already acted on the authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy. 


III. Uses and Disclosures with neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in certain situations as required by state and federal laws, including but not limited to, the following:

Child Abuse: If I have reasonable suspicion that a child (under the age of 18) is or has been the victim of child abuse or neglect, I must report this information. Also, if I have knowledge of or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional well-being is endangered in any other way, I may also report this information.

Abuse of an Elder or Dependent Adult: If I have reasonable suspicion that an elder (age 60 years or over) or dependent adult is or has been the victim of physical abuse, abandonment, abduction, isolation, financial abuse, neglect, or self-neglect, I must report this information.

Serious Threat to Self or Others: If you communicate to me (or if your family member informs me that you have communicated) a serious threat of physical violence against a reasonably identifiable victim(s), I have a duty to warn and protect and must make reasonable efforts to communicate the threat to the potential victim(s) and the to a law enforcement agency. If I have reasonable cause to believe that you are dangerous to yourself or others, I may release relevant information as necessary to prevent the threatened danger. Examples of such actions may include notifying the police, warning potential victim(s), arranging for your hospitalization.

Health Oversight: I may share health information for health oversight activities, such as audits and investigations. If a lawsuit or complaint with the California Board of Psychology is filed against me, I may release PHI in response.

Judicial or Administrative Proceedings: I may be required to share health information about you if I receive a court or administrative order, or in response to a subpoena. If you are involved in a court proceeding and a request is made for information about the professional services that I provided you and/or the records thereof, such information is privileged under state law, and I may not release information without your written authorization or a court order. Privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered; you will be informed in advance if this is the case.

Worker’s Compensation: If you file a worker’s compensation claim, I may be required by law to disclose PHI to your employer or other involved parties.

When allowed under other sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law: This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

IV. Patient’s Rights and Psychologist’s Duties

Patient’s Rights:

The right to get an electronic or paper copy of your medical record. You can ask to see or receive an electronic or paper copy of your medical record and other health information I have about you. Ask me how to do this. I will provide a copy or a summary of your health information, usually within 30 days of your written request. I may charge a reasonable, cost-based fee.

The right to ask me to correct your medical record. You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this. I may say “no” to your request, but I’ll tell you why in writing within 60 days.

The right to request confidential communications. You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address. I will say “yes” to all reasonable requests.

The right to ask me to limit what I use or share. You can ask me not to use or share certain health information for treatment, payment, or operations. I am not required to agree to your request, and I may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or our operations with your health insurer. I will say “yes” unless a law requires us to share that information.

The right to get a list of those with whom I’ve shared information. You can ask for a list (accounting) of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with, and why. I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make). I’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

The right to get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.

The right to 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 and make choices about your health information. I will make sure the person has this authority and can act for you before I take any action.

The right to file a complaint if you feel your rights are violated. You can complain if you feel I have violated your rights by contacting me by mail at P.O. Box 27561, Los Angeles, CA 90027, email at danielle@dgpsych.com, or by phone at 310-426-8035. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. I will not retaliate against you for filing a complaint.

Psychologist’s Duties:

I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

I will inform you promptly if a breach occurs that creates a high probability that the privacy and security of your PHI may have been compromised.

I will not sell or market your PHI.

I will follow the duties and privacy practices described in this notice. I reserve the right to change the privacy policies and practices described in this notice.

V. Questions

I, Danielle Gissinger, Ph.D., am the designated Security Officer and Privacy Officer of this practice. If you have questions about this Notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, please let me know.

VI. Effective Date and Changes to the Terms of this Notice

This notice is effective on August 31, 2024. If there are changes to the terms of this Notice, the revised Notice will be available upon request, in my office, and on my website.