Notice of Privacy Practices

James J. De Santis, Ph.D.
Post Office Box 894, Glendora, CA 91740-0894
(818) 551-1714

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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUMAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY. WE WILL ASK YOU TO SIGN
A FORM INDICATING THAT YOU HAVE RECEIVED THIS INFORMATION.

We have built our practice in this community on a foundation of integrity,
respect, and professionalism. These values are reflected in our longstanding
commitment to protect your privacy. Fully advising your psychologist of
your physical and emotional condition is important in allowing your
psychologist to provide optimal service to you.

In order for you to feel comfortable doing this, your privacy is of the highest
priority. That is why we want you to know how we protect the information
you share with us. Psychologists have been, and continue to be, bound by
professional standards of confidentiality that are often more stringent than
those required by law; therefore, we have always protected your right to
privacy.

What Is "Protected Health Information" (PHI)?

When we psychologically examine, diagnose, treat, or refer you, we will be
collecting what the law calls Protected Health Information (PHI) about you.

PHI includes non-public information about you that we have created or
received about your past, present, or future health or condition, the
provision of health care to you, or the payment for this health care. This
may include your name, addresses, and phone numbers; your symptoms,
diagnoses, treatment goals, treatment methods, progress, and outcome;
others treating you; legal matters; payment information; and your personal
history or current situation.

We collect information about you from conversations with you in this office
or over the telephone, through questionnaires and forms we may ask you to
complete from time to time, from psychological tests we may administer to
you, and from observing you over time in the course of providing
professional services to you, as well as information received from others,
such as family members or other professionals.

How, When, and Why We Use Your Information

Your psychologist might use or disclose your health information for many
different reasons.

A "use" of information occurs when we examine, utilize, apply, or analyze
such information within our practice for the purpose of providing
professional services. A "disclosure" occurs when it is released or
transferred to a third party outside of our practice for the purpose of
providing professional services.

Your psychologist will not use or disclose any more of your information than
is necessary to accomplish the purpose for which the use or disclosure is
made.

We will routinely use your information to address your symptoms, problems,
and personal goals. We may use your information to select methods of
treatment, offer additional services to you, or recommend referrals to other
professionals for services we do not provide.

We may use your information to review our clinical practices for quality
assurance purposes, to evaluate and improve the effectiveness of health
care services that you received.

We may be required by clinical standards, professional ethics, or law to
disclose limited information to specific professionals or agencies for optimal
professional care to you, where you have requested or consented to a
disclosure or waived your privacy, or in some instances for safety.

If you are using health insurance and we accept responsibility for collecting
payment, it will be necessary for us to disclose limited personal information
to your insurance company to obtain eligibility and benefit information as
well as to bill and collect payment for the treatment and services provided
by us to you. For example, we usually have to provide your name, address,
employer, social security number, date of birth, diagnosis, and dates that
services were rendered.

Appropriate written records of service are required by clinical standards,
ethics, and law. We create and retain written records relating to
professional service that we provide so that we are better able to assist
you with your needs and provide quality service to you. We document
services to show we actually provided services to you which we billed to
you or your insurance company. Personal information we receive about you
may be entered into this record.

Safeguards of Your Privacy

We pledge to take measures to safeguard the information of current and
former patients. In order to protect this information against unauthorized
access, we maintain physical, electronic, and procedural safeguards that
comply with state and federal regulations.

As a general principal, we do not disclose any personal information about
our patients or former patients to anyone, not even acknowledging that we
know you or that you are receiving services from us. If your psychologist
receives a request from third parties for your information or records, he will
consult you first. He will not disclose your information to other health
professionals, to your family members, or to members of the general public
without your prior consent.

Your psychologist strives to keep any communication between you and him
discrete. Communication by you to your psychologist, whether by phone,
mail, or in person, will be handled only by your psychologist. Voicemail and
computer records are password-protected. Your psychologist will attempt
to leave voicemail messages that are discrete if he does not know who
might access your messages. He will avoid sensitive subject matter in
semi-public areas such as the waiting room or corridor, unless you initiate.
Your psychologist will not acknowledge you if you inadvertently see each
other in a public place, unless you initiate.

We do not recommend e-mail communication between psychologist and
patient because encryption technology is constantly evolving and may be
subject to unauthorized intrusion.

We will not provide your information to accountants, attorneys, or other
business consultants involved in our practice. We have no employees in our
practice; however, in the event that we do in the future, we will require a
written agreement from them to maintain your privacy.

Any institutions outside our office that will have access to your information,
such as insurance companies, billing services, or typing services, are
similarly required to protect your information by contract or law.

Records that have been provided to us by other health care professionals
will not be re-released by us.

Records may only be destroyed after a period of time prescribed by ethics
and law. We keep our records at a remote location, transport only in a
secure manner, and store them under lock and key inaccessible to others.

To maintain the highest ethical and legal standards of protecting your
privacy, we will adhere to these policies and may amend them in the future
as needed to remain current with law and ethics. Any changes will apply to
all information we maintain at that time.

Disclosures Allowed with Your Consent

Disclosures of any of your information generally require your prior consent,
which must include what will be released, to whom, and for what purpose.
We ask that you agree to these policies, below.

1. To ensure that services are consistent with current and prior treatment
and that important facts leading to your diagnosis and treatment are not
overlooked, we may ask for your consent in writing to communicate with or
obtain records from other treating professionals, such as your physician or
another therapist, who are either currently, have formerly, or will be
providing service to you.

2. To maintain high standards of care, a psychologist periodically obtains
consultation from colleagues about cases. In such consultations,
information which would identify you will not be disclosed.

3. When services are paid by a third party such as an insurance company,
you usually have waived your right to complete confidentiality as part of
the terms of your policy. A psychologist may therefore be required by your
carrier as part of the terms of your coverage to disclose information or
records in order to process a claim. You hereby authorize such disclosures if
you request payment by a third party.

4. If you bring a family member to your appointment and disclose
information in their presence, that information is considered disclosed to
them. We will disclose your information in such a session with your verbal
permission.

5. When a couple is being seen in treatment, the psychologist's policy is
that he cannot keep secrets from either partner.

6. If you are under age 18, you have the right to confidentiality, but your
parents, including a non-custodial parent, have a right to know about your
treatment. Unless there is a serious danger, the psychologist will provide
parents with only general information about the content of sessions held
with teenagers.

7. If you send me an e-mail or if you ask me to respond to you about
something via an e-mail, you must understand that it may not be entirely
confidential.

8. In the event your psychologist is incapacitated, he has designated one
trusted colleague to administer all confidential matters as necessary for the
continuity of your care. You hereby authorize your psychologist to release
your information under these circumstances.

9. In the event your psychologist closes or transfers his practice, you
hereby authorize him to place your record in the custody of a trusted
colleague for proper storage, retrieval, and disposal under these
circumstances.

10. Other uses and disclosures not described in this Privacy Notice will be
made only with authorization from the patient.

You can cancel your authorization by putting your request in writing at any
time to stop any future uses and disclosures of your information by us, to
the extent that we have not already taken action in reliance on such
authorization and to the extent that disclosure is not required by law.

Legally Mandated Exceptions to Privacy

Your information is private with some rare but important legally mandated
exceptions.

1. If you present an immanent danger to yourself or others or are unable to
care for yourself, limited information may be disclosed to facilitate
hospitalization for your protection.

2. If you or a member of your family communicate to a psychologist a
serious threat of immanent physical harm by you to an identifiable person or
the public or of property damage, the psychologist must warn the person as
well as public law enforcement agencies reasonably able to prevent or
lessen such harm.

3. If there is a reasonable suspicion of abuse or neglect of an identifiable
child, elder, or dependent adult, a report may be required to designated
public agencies. A patient's disclosure of viewing child pornography
constitutes a reason to suspect and report.

4. If a valid medical emergency exists, for example if you become
unconscious in the office or are in severe pain and cannot communicate,
your psychologist may summon emergency medical services and/or call the
emergency contact you named on the information form.

5. In some legal proceedings, such as where your emotional condition is an
important issue, a judge may order records or testimony concerning you or
your family without your consent.

6. If you fail to assume financial responsibility for your bill, limited personal
information may be disclosed for purposes of debt collection, such as your
name, date and type of services you have received, and the amount due.

7. If you are incapacitated or deceased, your information remains secure.
However, disclosure may be authorized by the entity with health care power
of attorney or charged with making decisions about your estate.

8. We may be required to disclose some information to government agencies
which check to see that we are obeying the privacy laws.

What Rights You Have Regarding Privacy

Although your record is the physical property of the healthcare practitioner
that collected it, the information belongs to you. We respect your privacy
choices.

You have the right to ask that we limit how we use or disclose your
information. You will have to tell us what you want. Although we will
consider every request and try to respect your wishes, we will exercise
professional judgement in each instance. If we accept your request, we will
abide your wishes except in emergency situations. You cannot limit the uses
or disclosures that we are legally required to make.

Patients have the right to restrict certain disclosures of PHI to health
insurance companies if the patient pays out of pocket in full for the health
care service. Most uses and disclosures of psychotherapy notes, uses and
disclosures of protected health information (PHI) for marketing purposes,
and disclosures that constitute a sale of PHI require patient authorization.

In most cases, you have the right to look at or get a copy of information
that we have, but you must make the request in writing. If we don't have
your information but know who does, we will tell you how to get it. In
certain situations, such as if we believe specific information may cause
harm to you, we may deny your request. If we do, we will tell you, in
writing, our reasons for the denial, and explain your right to have our denial
reviewed.

If you request a copy of your information, there may be a reasonable
charge for our time and copying and delivery costs. Instead of providing the
information you requested, we may provide you with a summary or
explanation of the information as long as you agree to that and any cost in
advance.

If you believe that there is a mistake in your information or that a piece of
important information is missing, you have the right to request that we
correct the existing information or add the missing information. You must
provide the request and your reason for the request in writing.

In the event of a breach of unsecured protected health information,
affected patients have the right to be notified. You have the right to get a
list of instances in which we have disclosed your information. The list will
not include uses or disclosures that you have already consented to such as
those made for treatment, payment, or health care operations, directly to
you, or to your family. The list also won't include uses or disclosures made
before April 14, 2003.

You have the right to ask that we send information to you at an alternate
address (for example, sending information to your work address rather than
your home address) or by alternate means (for example, e-mail instead of
regular mail). We must agree to your request so long as we can easily
provide the information to you in the format you requested.

In the future we may change how we use and share your information and so
may change this Notice of Privacy Practices. You can obtain the most
current copy from the internet at http://hometown.aol.com/jjdesantis, by
calling us at (818) 551-1714, or by requesting it in person or by mail from
us.

Questions or Complaints about Privacy

If you have questions or believe your privacy has been violated, you are
encouraged to address your concerns with your psychologist, James J. De
Santis, Ph.D., 138 North Brand Boulevard, Suite 300, Glendale, CA
91203-4618, (818) 551-1714, www.JJDeSantis.com. You may also contact
the Secretary of the Department of Health and Human Services at 200
Independence Avenue S.W., Washington, DC 20201, by calling (202)
619-0257, or by accessing the internet at http://www.hhs.gov/ocr/hipaa.
We will not limit your care or take any action against you if you complain.

This notice went into effect on 04/14/2003. Last Update: 09/20/2016.