North Berkeley Counseling Collective HIPAA Privacy practices
Telegraph Psychology Collective/North Berkeley
Counseling Collective HIPAA Notice of Privacy
Practices
NOTICE OF PRIVACY PRACTICES
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on September 1, 2026.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY and if you have questions or concerns, please contact:
Security Officer: Danielle Kassouf, PsyD
Address: Telegraph Psychology Collective PC (DBA North Berkeley Counseling
Collective) at 264 Arlington Ave, Suite 3, Kensington, CA 94707
Telephone: 510-224-5591
Security Email: hello@drdaniellekassouf.com
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
Template library
ways in which I may use and disclose health information about you. I also describe your
Intake documents, progress notes, treatment plans, and other documents
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:
Shareable documents
Make sure that protected health information (“PHI”) that identifies you is kept
Manage default intake documents and uploaded files
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.
Notify you following any breach of your unsecured PHI as required by law.
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.
Treatment, Payment, and Health Care Operations: Federal privacy law permits the
Practice to use and disclose protected health information (“PHI”), without your written
authorization, for certain treatment, payment, and health care operations activities. The
Practice may use your PHI internally as reasonably necessary to provide and coordinate
your care and to perform authorized clinical, administrative, billing, compliance, and
practice-management functions.
Although HIPAA may permit the Practice to disclose your PHI to another health care
provider for that provider’s treatment activities without your written authorization, it is
the Entity and Provider’s policy ordinarily to obtain your written authorization before
voluntarily disclosing identifiable clinical information to an outside health care provider
for treatment or care-coordination purposes. This includes communications with your
physician, psychiatrist, former therapist, or another outside treating professional.
This policy does not prevent the Entity or Provider from using or disclosing PHI without
authorization when the disclosure is required by law or otherwise necessary and
permitted in circumstances such as a medical or psychiatric emergency, a serious threat
to health or safety, suspected abuse or neglect, a valid court order, or another legally
recognized exception described in this Notice.
The Practice may also use and disclose the minimum PHI reasonably necessary for
payment and health care operations, including verifying insurance eligibility and
benefits; obtaining authorization; submitting and correcting claims; responding to
requests concerning coverage, medical necessity, utilization review, claim appeals,
quality review, fraud prevention, or payer audits; and performing billing, legal,
compliance, and practice-administration activities. These disclosures generally do not
require a separate written authorization.
Substance Use Disorder Records: If the Practice receives or maintains substance use
disorder treatment records that are protected by 42 C.F.R. Part 2, additional federal
confidentiality protections apply. Certain uses and disclosures of those records require
your written consent unless another specific provision of law permits the use or
disclosure. When Part 2 records are disclosed pursuant to a valid consent for treatment,
payment, or health care operations, a HIPAA-regulated recipient may be permitted to
use and redisclose the information as allowed by HIPAA. However, Part 2 records
generally may not be used or disclosed in civil, criminal, administrative, or legislative
proceedings against you without your specific written consent or a qualifying court order
and subpoena. Other restrictions may also apply.
Additional protections under California law: California law may provide greater
protection than HIPAA for certain information, including information concerning
treatment of minors, immigration status or place of birth, reproductive health care,
gender-affirming care, mental health treatment, and other specially protected
information. The Practice will comply with the more protective applicable law.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health informationin 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. A
subpoena, discovery request, or demand from an attorney does not necessarily
authorize disclosure. The Practice will disclose records or testimony only when
authorized by the patient or personal representative, required by a valid court order, or
otherwise permitted or required by applicable law. When appropriate, the Treating
Clinician or Practice may assert the psychotherapist-patient privilege on the patient’s
behalf. 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 may 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.
2. 3. 4. 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.
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.
Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for
marketing purposes.
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 yourAuthorization 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. 4. For health oversight activities, including audits and investigations.
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. 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.
8. 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.
9. 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. By law, 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. However, it is
the practice of Entity and Provider to obtain written authorization to disclose PHI to
your contacts unless required in an emergency situation. The opportunity to
consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
1. 2. 3. 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.
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.
The Right to Choose How I Send PHI to You. You have the right to ask me to contactyou 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 15 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. To the extent required by applicable law, you may 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. 7. The right to be notified in the case of a breach of unsecured PHI.
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.
8. 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.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us using the
information on page 1.
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
https://www.hhs.gov/hipaa/filing-a-complaint/index.html.
We will not retaliate against you for filing a complaint.
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.