MOOD CLINICAL P.C. Summary Notice Of Privacy Practices

Your Protected Health Information (PHI)

“Protected health information” (PHI) is information about you, including demographic information, that may identify you or be used to identify you, and that relates to your past, present or future physical or mental health or condition, the provision of health care services, or the past, present or future payment for the provision of health care. Each time you have contact with a healthcare provider for delivery of healthcare, a record of your contact/visit is prepared. Your medical record is the physical property of Mood Clinical, MD, P.C. (“P.C.”), but you have certain rights to restrict, or request restrictions on, some of the uses or disclosures of the information in your medical record, as further described in this Notice. However, P.C. has the right to use and disclose the information contained in your medical record in the process of providing treatment, seeking or receiving payment, and performing other regular health care operations, as is further described herein.

Your Rights Regarding Your PHI

Except as otherwise provided by applicable law, you have the right to:

Inspect and copy your PHI and other medical records

• You may request to inspect or receive a copy of your PHI or other medical records about you that are maintained in a designated record set.

• So long as P.C. maintains the requested information in the designated record set, P.C. will provide you with a copy or summary of such information. P.C. may charge a reasonable, cost-based fee for providing such information.

Request an amendment to your PHI and other medical records

• You may request that P.C. amend PHI or other medical records about you in a designated record set that you believe to be incomplete or inaccurate.

• P.C. is not required to change any such information if P.C. deems such information to be accurate or if the information was provided from another source.

• If P.C. does not change any such information, it will provide you with the reason for not doing so in a timely manner.

Request confidential communications

• You may request in writing to receive confidential communications from P.C. regarding your PHI or other medical records.

• P.C. will agree to all reasonable requests of this nature.

Request restrictions on the uses or disclosures of PHI

• You may request that P.C. restrict uses or disclosures of your PHI in connection with treatment, payment, or health care operations. P.C. is not required to agree to such a restriction. However, to the extent that P.C. does agree with your request, P.C. may not use or disclose the protected PHI in violation of the restriction unless the PHI is needed to provide emergency treatment or is otherwise permitted or required by law.

• If you pay for a service or health care item out-of-pocket in full, you can ask P.C. not to share that information for the purpose of payment or P.C. operations with your health insurer. P.C. will say “yes” unless a law requires P.C. to share that information.

Receive an accounting of PHI disclosures

• You may ask for a list (an accounting) of the times P.C. has shared your PHI for reasons other than treatment, payment, healthcare operations, or other disclosures you requested P.C. to make during the six (6) years prior to the date of request, along with the persons or entities with whom the PHI was shared and the reasons for such disclosure.

• P.C. will provide one (1) accounting per twelve (12) month period free of charge but will charge you a reasonable, cost-based fee if you ask for another accounting within twelve (12) months.

Receive a copy of this Notice

• You may request to receive a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically. P.C. will provide you with a paper copy of the Notice in a prompt and timely manner.

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.

Additional rights; Complaint procedures

• P.C. is required by law to maintain the privacy and confidentiality of your PHI and to provide you with notice of its legal duties and privacy practices with respect to such health information.

• P.C. is also required by law to abide by the terms of this Notice, allow you to review this Notice prior to granting assent, and notify you of any changes and revisions to this Notice.

• If you believe that your privacy rights have been violated, you may submit a written complaint to P.C. by contacting us at privacy@moodclinical.com

  or by mail at:

  18191 Von Karman Ave Ste 100 Irvine, CA 92612-7103

• You may also 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/.

• P.C. will not retaliate against you in the event that you file a complaint.

Your Choices

For certain health information, you can tell P.C. your choices about what P.C. may share. If you have a clear preference for how P.C. shares your information in the situations described below, please contact P.C. at privacy@moodclinical.com with your preferences and P.C. will follow your instructions with respect to the your rights and choices in connection with the below:

• Instructions on sharing information with your family, close friends, or others involved in your care.

P.C. may ask you to provide the name and contact information for friends and family members who you want to be involved in your care, and will abide by your instructions. If you are not able to communicate your preferences to P.C. (such as instances when you are unconscious), P.C. may proceed with sharing your information if P.C. believes doing so is in your best interest. P.C. may also share your information when needed to lessen a serious and imminent threat to health or safety.

In the below cases, P.C. will never share your information unless you provide P.C. with written permission to do so:

• Sharing of psychotherapy consultation session notes that are maintained separately from the rest of the medical record.

Our Uses and Disclosures of PHI

P.C. may use and share your PHI and other health information in connection with providing treatment, receiving payment for health services, and performing other regular health operations such as:

• Documenting and describing the care you received for legal purposes;

• Communicating with other healthcare providers who may be involved in your care;

• Educating health care professionals;

• Conducting medical research;

• Providing information for government and public health entities responsible for improving public health and welfare;

• Evaluating and improving the care you receive and the outcomes achieved;

• Billing and verification of services provided to you; and

• Conducting other routine healthcare operations such as quality improvement studies and assessing healthcare provider competence.

Examples of Uses and Disclosures of Your PHI

P.C. typically uses or shares your health information in the following ways.

Healthcare Delivery and Treatment

Information obtained from you by a physician, nurse, or other healthcare professional is documented in your record and used for the assessment, evaluation, diagnosis, and treatment of your medical condition(s). Following your treatment, this information may be provided to other healthcare professionals who may be involved in your care, such as other physicians, specialists, physical therapists, hospital-based providers, and/or other healthcare providers.

Example: Your physician and an P.C. provider may need to coordinate your care.

Billing and Payment

Your PHI is utilized to justify the level of care delivered to you and the charges incurred for the services. This information generally accompanies the bill and is sent to our payers.

Example: P.C. gives information about you to your health insurance plan so it will pay for your services.

Healthcare Operations

P.C. may disclose your PHI to other individuals and businesses in order to perform day-to-day operations. These other individuals and businesses include business associates such as vendors and/or contractors used for billing and claims management, medical research, disease management, and quality improvement initiatives, as well as management services organizations, laboratories, other free-standing diagnostic facilities, and legal counsel. P.C. requires all business associates to agree to appropriately protect the confidentiality of your PHI.

Example: P.C. uses health information about you to manage the way P.C. provides your treatment and services.

How else can P.C. use or share your health information?

P.C. is allowed or may be required to share your PHI or other health information in other ways – usually in ways that contribute to the public good, such as public health and research, which are summarized below. P.C. has to meet many conditions in the law before P.C. can share your information for these purposes. For more information on these permitted disclosures, please see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

To help with public health and safety issues

P.C. can share health information about you for certain situations such as: Reporting suspected abuse, neglect, or domestic violence; or Preventing or reducing a serious threat to anyone’s health or safety.

To conduct research

P.C. can use or share your information for health research where permitted by law or with your consent.

To comply with the law

P.C. will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that P.C. is complying with federal privacy law.

For Reminders and Treatment

P.C. may contact you to provide you with information P.C. feels is useful or helpful to you, based on your PHI. For example, P.C. may contact you (or instruct a specialist provider to whom you have been referred to contact you) to schedule an appointment or as an appointment reminder, to suggest alternative treatments, or to provide you with information on treatments you are already receiving.

For Legal Reasons

P.C. can use or share health information about you:

• For workers’ compensation claims;

• For law enforcement purposes or with a law enforcement official;

• With health oversight agencies for activities authorized by law;

• For special government functions such as military, national security, and presidential protective services; or

• In response to a court or administrative order.

Other Miscellaneous Uses

• P.C. may also utilize or disclose your PHI in order to communicate with or notify family members, relatives, and others responsible for your health, and funeral directors.

• P.C. may disclose your PHI through other communications and reports required to be made by healthcare professionals, such as the public health department, law enforcement, the Food and Drug Administration, organ procurement organizations, correctional institutions, and workers compensation, where applicable.

• Other uses and disclosures of PHI not permitted or required by law will be made only with your written authorization. You may revoke your authorization at any time; provided, that the revocation is in writing, except to the extent that P.C. has already taken action in reliance on your prior authorization.

Our Responsibilities

• P.C. is required by law to maintain the privacy and security of your protected health information.

• P.C. will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• P.C. must follow the duties and privacy practices described in this Notice and give you a copy of it. P.C. will not use or share your health information other than as described here unless you permit otherwise in writing. If you authorize P.C. to use or share your health information for additional purposes, you may revoke such additional authorization at any time in writing.

For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

P.C. may change the terms of this Notice, and the changes will apply to all information P.C. has about you. The new Notice will be available upon request, in P.C.’s offices, and on the P.C. website.

These Privacy Practices were last modified on March 28, 2022.