North Berkeley Counseling Collective HIPAA Privacy practices

HIPAA NOTICE OF PRIVACY PRACTICES

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Effective Date: February 2, 2017
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
The terms of this Notice of Privacy Practices (“Notice”) apply to [Telegraph Psychology Collective PC (DBA North Berkeley Counseling Collective)], and its affiliates. [Telegraph Psychology Collective PC (DBA North Berkeley Counseling Collective)]will share protected health information of patients as necessary to carry out
treatment, payment, and health care operations as permitted by law.
We are required by law to maintain the privacy of our patients' protected health information and to provide
patients with notice of our legal duties and privacy practices with respect to protected health information.
We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right
to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for
all protected health information maintained by [Telegraph Psychology Collective PC (DBA North Berkeley Counseling Collective)]. We are required to notify you in the event of
a breach of your unsecured protected health information. We are also required to inform you that there may
be a provision of state law that relates to the privacy of your health information that may be more stringent
than a standard or requirement under the Federal Health Insurance Portability and Accountability Act
(“HIPAA”). A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law
may be obtained by mailing a request to the Privacy Officer at the address below.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION:
Authorization and Consent: Except as outlined below, we will not use or disclose your protected health
information for any purpose other than treatment, payment or health care operations unless you have signed
a form authorizing such use or disclosure. You have the right to revoke such authorization in writing, with
such revocation being effective once we actually receive the writing; however, such revocation shall not be
effective to the extent that we have taken any action in reliance on the authorization, or if the authorization
was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to
contest a claim under the policy or the policy itself.
Uses and Disclosures for Treatment: We will make uses and disclosures of your protected health
information as necessary for your treatment. Doctors and nurses and other professionals involved in your
care will use information in your medical record and information that you provide about your symptoms and
reactions to your course of treatment that may include procedures, medications, tests, medical history, etc.
Uses and Disclosures for Payment: We will make uses and disclosures of your protected health
information as necessary for payment purposes. During the normal course of business operations, we may
forward information regarding your medical procedures and treatment to your insurance company to arrange
payment for the services provided to you. We may also use your information to prepare a bill to send to you
or to the person responsible for your payment.

Uses and Disclosures for Health Care Operations: We will make uses and disclosures of your protected
health information as necessary, and as permitted by law, for our health care affiliate's operations, which may include
clinical improvement, professional peer review, business management, accreditation and licensing, etc. For
instance, clinician affiliates and insurance payers may use and disclose your protected health information for purposes of improving clinical
treatment and patient care.
Individuals Involved In Your Care: We may from time to time disclose your protected health information
to designated family, friends and others who are involved in your care or in payment of your care in order to
facilitate that person's involvement in caring for you or paying for your care. If you are unavailable,
incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be
in your best interest, we may share limited protected health information with such individuals without your
approval. We may also disclose limited protected health information to a public or private entity that is
authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons
that may be involved in some aspect of caring for you.
Business Associates: Certain aspects and components of our services are performed through contracts
with outside persons or organizations, such as auditing, accreditation, outcomes data collection, legal
services, etc. At times it may be necessary for us to provide your protected health information to one or
more of these outside persons or organizations who assist us with our health care operations. In all cases,
we require these associates to appropriately safeguard the privacy of your information.
Appointments and Services: We may contact you to provide appointment updates or information about
your treatment or other health-related benefits and services that may be of interest to you. You have the
right to request and we will accommodate reasonable requests by you to receive communications regarding
your protected health information from us by alternative means or at alternative locations. For instance, if
you wish appointment reminders to not be left on voice mail or sent to a particular address, we will
accommodate reasonable requests. With such request, you must provide an appropriate alternative
address or method of contact. You also have the right to request that we not send you any future marketing
materials and we will use our best efforts to honor such request. You must make such requests in writing,
including your name and address, and send such writing to the Privacy Officer at the address below.
Research: In limited circumstances, we may use and disclose your protected health information for
research purposes. In all cases where your specific authorization is not obtained, your privacy will be
protected by strict confidentiality requirements applied by an Institutional Review Board which oversees the
research or by representations of the researchers that limit their use and disclosure of your information.
Fundraising: We may use your information to contact you for fundraising purposes. We may disclose this
contact information to a related foundation so that the foundation may contact you for similar purposes. If
you do not want us or the foundation to contact you for fundraising efforts, you must send such request in
writing to the Privacy Officer at the address below.
Other Uses and Disclosures: We are permitted and/or required by law to make certain other uses and
disclosures of your protected health information without your consent or authorization for the following:
• Any purpose required by law;
• Public health activities such as required reporting of immunizations, disease, injury, birth and
death, or in connection with public health investigations;
• If we suspect child abuse or neglect; if we believe you to be a victim of abuse, neglect or
domestic violence;
• To the Food and Drug Administration to report adverse events, product defects, or to
participate in product recalls;
• To your employer when we have provided health care to you at the request of your employer;
• To a government oversight agency conducting audits, investigations, civil or criminal
proceedings;
• Court or administrative ordered subpoena or discovery request;
• To law enforcement officials as required by law if we believe you have 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 coroners and/or funeral directors consistent with law;
• If necessary to arrange an organ or tissue donation from you or a transplant for you;
• If you are a member of the military, we may also release your protected health
information for national security or intelligence activities; and
• To workers' compensation agencies for workers' compensation benefit determination.
DISCLOSURES REQUIRING AUTHORIZATION:
Psychotherapy Notes: We must obtain your specific written authorization prior to disclosing any
psychotherapy notes unless otherwise permitted by law. However, there are certain purposes for which we
may disclose psychotherapy notes, without obtaining your written authorization, including the following: (1) to
carry out certain treatment, payment or healthcare operations (e.g., use for the purposes of your treatment,
for our own training, and to defend ourselves in a legal action or other proceeding brought by you), (2) to the
Secretary of the Department of Health and Human Services to determine our compliance with the law, (3) as
required by law, (4) for health oversight activities authorized by law, (5) to medical examiners or coroners as
permitted by state law, or (6) for the purposes of preventing or lessening a serious or imminent threat to the
health or safety of a person or the public.
Genetic Information: We must obtain your specific written authorization prior to using or disclosing your
genetic information for treatment, payment or health care operations purposes. We may use or disclose
your genetic information, or the genetic information of your child, without your written authorization only
where it would be permitted by law.
Marketing: We must obtain your authorization for any use or disclosure of your protected health information
for marketing, except if the communication is in the form of (1) a face-to-face communication with you, or (2)
a promotional gift of nominal value.
Sale of Protected Information: We must obtain your authorization prior to receiving direct or indirect
remuneration in exchange for your health information; however, such authorization is not required where the
purpose of the exchange is for:
• Public health activities;
• Research purposes, provided that we receive only a reasonable, cost-based fee to cover the
cost to prepare and transmit the information for research purposes;
• Treatment and payment purposes;
• Health care operations involving the sale, transfer, merger or consolidation of all or part of our
business and for related due diligence;
• Payment we provide to a business associate for activities involving the exchange of protected
health information that the business associate undertakes on our behalf (or the subcontractor
undertakes on behalf of a business associate) and the only remuneration provided is for the
performance of such activities;
• Providing you with a copy of your health information or an accounting of disclosures;
• Disclosures required by law;
• Disclosures of your health information for any other purpose permitted by and in accordance
with the Privacy Rule of HIPAA, as long as the only remuneration we receive is a reasonable,
cost-based fee to cover the cost to prepare and transmit your health information for such
purpose or is a fee otherwise expressly permitted by other law; or
• Any other exceptions allowed by the Department of Health and Human Services.
RIGHTS THAT YOU HAVE REGARDING YOUR PROTECTED HEALTH INFORMATION:
Access to Your Protected Health Information: You have the right to copy and/or inspect much of the
protected health information that we retain on your behalf. For protected health information that we maintain
in any electronic designated record set, you may request a copy of such health information in a reasonable
electronic format, if readily producible. Requests for access must be made in writing and signed by you or
your legal representative. You may obtain a "Patient Access to Health Information Form" from the front
office person. You will be charged a reasonable copying fee and actual postage and supply costs for your
protected health information. If you request additional copies you will be charged a fee for copying and
postage.
Amendments to Your Protected Health Information: You have the right to request in writing that
protected health information that we maintain about you be amended or corrected. We are not obligated to
make requested amendments, but we will give each request careful consideration. All amendment requests,
must be in writing, signed by you or legal representative, and must state the reasons for the
amendment/correction request. If an amendment or correction request is made, we may notify others who
work with us if we believe that such notification is necessary. You may obtain an "Amendment Request
Form" from the front office person or individual responsible for medical records.
Accounting for Disclosures of Your Protected Health Information: You have the right to receive an
accounting of certain disclosures made by us of your protected health information after April 14, 2003.
Requests must be made in writing and signed by you or your legal representative. "Accounting Request
Forms" are available from the front office person or individual responsible for medical records. The first
accounting in any 12-month period is free; you will be charged a fee for each subsequent accounting you
request within the same 12-month period. You will be notified of the fee at the time of your request.
Restrictions on Use and Disclosure of Your Protected Health Information: You have the right to
request restrictions on uses and disclosures of your protected health information for treatment, payment, or
health care operations. We are not required to agree to most restriction requests, but will attempt to
accommodate reasonable requests when appropriate. You do, however, have the right to restrict disclosure
of your protected health information to a health plan if the disclosure is for the purpose of carrying out
payment or health care operations and is not otherwise required by law, and the protected health information
pertains solely to a health care item or service for which you, or someone other than the health plan on your
behalf, has paid [Telegraph Psychology Collective PC (DBA North Berkeley Counseling Collective)]in full. If we agree to any discretionary restrictions, we reserve the right to
remove such restrictions as we appropriate. We will notify you if we remove a restriction imposed in
accordance with this paragraph. You also have the right to withdraw, in writing or orally, any restriction by
communicating your desire to do so to the individual responsible for medical records.
Right to Notice of Breach: We take very seriously the confidentiality of our patients’ information, and we
are required by law to protect the privacy and security of your protected health information through
appropriate safeguards. We will notify you in the event a breach occurs involving or potentially involving
your unsecured health information and inform you of what steps you may need to take to protect yourself.
Paper Copy of this Notice: You have a right, even if you have agreed to receive notices electronically, to
obtain a paper copy of this Notice. To do so, please submit a request to the Privacy Officer at the address
below.

Complaints: If you believe your privacy rights have been violated, you can file a complaint in writing with
the Privacy Officer. You may also file a complaint with the Secretary of the U.S. Department of Health and
Human Services at the below address. There will be no retaliation for filing a complaint.
Office for Civil Rights
Department of HHS
Jacob Javits Federal Building
26 Federal Plaza - Suite 3312
New York, NY 10278
Voice Phone (212) 264-3313
FAX (212) 264-3039
TDD (212) 264-2355
For Further Information: If you have questions, need further assistance regarding or would like to submit a
request pursuant to this Notice, you may contact the [Telegraph Psychology Collective PC (DBA North Berkeley Counseling Collective)]Privacy Officer by phone at (415-295-6457)
or at the following address: 27 Maiden Lane, San Francisco, CA 94108

 

UPDATED TERMS 5/29/2026

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I 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 this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• I am also required by law to provide you with adequate notice of your rights and my legal duties if I create or maintain records protected by 42 C.F.R. Part 2.

• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

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

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures 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.

For Treatment, Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

If your records are protected under 42 C.F.R. Part 2, certain uses and disclosures permitted by HIPAA for treatment, payment, and health care operations are materially limited by the stricter standards of those regulations. Furthermore, information disclosed pursuant to these rules may be subject to redisclosure by the recipient and may no longer be protected by federal privacy standards. 

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child 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 or to obtain an order protecting the information requested. However, for records protected by 42 C.F.R. Part 2, such records or testimony relaying their content shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless you provide specific written consent or a court order is issued in accordance with 42 C.F.R. Part 2.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

   • For my use in treating you.

   • For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

   • For my use in defending myself in legal proceedings instituted by you.

   • For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

   • Required by law and the use or disclosure is limited to the requirements of such law.

   • Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

   • Required by a coroner who is performing duties authorized by law.

   • Required to help avert a serious threat to the health and safety of others.

2. Substance Use Disorder (SUD) Counseling Notes. I may also maintain “SUD counseling notes,” which are notes recorded by a substance use disorder provider documenting the contents of a counseling session. Any use or disclosure of these notes requires your separate written authorization, which cannot be combined with a consent for other types of records. You can revoke your consent at any time except to the extent that I have already acted upon it to disclose these notes in accordance with your initial authorization.

3. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

4. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION:

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

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

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

2. Fundraising. If I intend to use or disclose your records protected by 42 C.F.R. Part 2 for fundraising for my benefit, I will provide you with a clear and conspicuous opportunity to opt-out before any such use or disclosure occurs.   

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone), or to send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes” and “SUD counseling notes” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request. You also have the right to request an accounting of disclosures specifically for your substance use disorder records protected under 42 C.F.R. Part 2. 

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.