The Shyness Clinic at the The Kurt and Barbara Gronowski Clinic at Pacific Graduate School of Psychology located in Los Altos, California.,

NOTICE OF PRIVACY PRACTICES

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

This notice will tell you about how The Shyness Clinic handles information about you. It explains how we use information here in this office, how we share it with other professionals and organizations, and how you can see it. It is important for you to know all of this so that you can make the best decisions for you and your family. The Shyness Clinic is required to tell you about this because of the privacy regulations of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This law and the laws of California are complicated and we don¹t want to make you read a lot that may not apply to you, so we have simplified some sections. Our practice is dedicated to maintaining the privacy of your health information. If you have any questions or want to know more about anything in this Notice, please ask Elaine Thomas, Psy.D. for more details.

After you have read this NPP we will ask you to sign a Consent Form to let us use and share your information as described here. If you do not sign this consent form we cannot treat you.

The Shyness Clinic has a legal duty to safeguard your protected health information, or PHI.

Each time you visit the Shyness Clinic or any doctor¹s office, hospital, clinic or any other "health care provider", information is collected about you and your physical and mental health. It may be information about your past, present or future health or conditions, or the treatment or other services you received from us or from others, or about payment for healthcare. The information we collect from you is called, in the law, Protected Health Information, or PHI. Some of the PHI that is likely to go into your record here includes:

Your name, date of birth, address and other contact information
Your social, educational, family, and work related history
Your reasons for seeking treatment at this time.
Your problems, symptoms, goals and needs.
Diagnoses. Diagnoses are the medical terms for problems and needs.
A treatment plan.
Progress notes.After each session we record our observations and your report of how things are going.
Records we receive from others who have treated or evaluated you.
Psychological testing information, school records, etc.
Information about medications you are currently taking or have taken in the past
Legal matters
Billing information

How your protected health information can be used and shared

When your information is shared, utilized, examined, applied or analyzed by the staff here at The Shyness Clinic, that is called, "use" in the law. If the information is shared with or sent to others outside this office, that is called, "disclosure" in the law. Except in some special circumstances, when we use your PHI here or disclose it to others we share only the minimum necessary PHI needed for the purpose. The following information is provided to meet the requirements of the law which gives you rights to know about your PHI, how it is used and your part in determining how it is disclosed. The Shyness Clinic is legally required to follow the privacy practices described in this Notice. However, The Shyness Clinic reserves the right to change the terms of this Notice and the privacy practices at any time. Any changes will apply to PHI on file at The Shyness Clinic already. Prior to making any important changes to this Notice and our privacy policies, an updated copy will be posted in the waiting area as well as on The Shyness Clinic¹s webpage, www.shyness.com.

The Shyness Clinic will use and disclose your PHI for many different reasons. For some of these uses or disclosures, The Shyness Clinic will need your prior authorization; for other uses and disclosures, however, The Shyness Clinic will not. Listed below are the different categories of the uses and disclosures along with some examples of each category.

Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations do not require your prior written consent. The Shyness Clinic can use and disclose your PHI without your consent for the following reasons:

For treatment: The Shyness Clinic is permitted by law to disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or who are involved in your care. Although such disclosure is permitted by the law, The Shyness Clinic policy is to seek and obtain written authorization from you before we disclose any information to other providers involved in your care. This information would include the fact that you are a client here. This is our policy because we believe that it is important that you are an active participant in the coordination of your care and because we aim to maintain your privacy. If you are being seen or have been seen by another provider who we believe can provide information to aid in your evaluation or treatment here, we will ask you to sign an authorization that allows us to release and exchange information with that provider.
To obtain payment for treatment: We may use your PHI to bill you. This bill will include your name, a diagnosis code, the dates and types of services provided, the treating therapist(s), and the charges billed and received. We will mail it to you at the address you have given us. We do not bill insurance companies directly. Should you wish to seek reimbursement for seeing an out of network provider from your insurance company, we can provide you with monthly statements which you can then submit directly to your insurance company. Included in statements that you submit to your insurance company will be a diagnosis code, the dates and types of services provided, the treating therapist(s), and the charges billed and received.

The Shyness Clinic may also provide your PHI to our bookkeeper who handles incoming payments and accounts. Our bookkeeper needs to receive some of your PHI in order to do their job properly. This information is limited to your name, the amount you paid, the method of payment (cash or check) the date you paid, the type of service you received (individual or group therapy) and the therapist who provided the service. To protect your privacy our bookkeeper has agreed in their contract with us to safeguard your information.
For health care operations: The Shyness Clinic may use or disclose your PHI in order to operate our practice. For example, we may use your PHI to see where we can make improvements in the care and services we provide. We may be required to supply some information to some government health agencies so they can study disorders and treatment and make plans for services that are needed. If we do, your name and identity will be removed from what we send.
Other disclosures: The Shyness Clinic may also disclose your PHI to others without your consent in certain situations. For example, your consent is not required if you need emergency treatment, as long as we try to obtain your consent after treatment is rendered, or if a therapist tries to get your consent but you are unable to communicate (for example, you are unconscious or in severe pain) and the therapist believes that you would consent to such treatment were you able to do so.

Certain Uses and Disclosures Do Not Require Your Consent. The Shyness Clinic can use and disclose your PHI without your consent or authorization for the following reasons:

When disclosure is required by federal, state, or local law; judicial or administrative proceedings; or law enforcement. For example, The Shyness clinic may make a disclosure to applicable officials when a law requires us to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding. Specific situations that might arise include:
- a. if a patient communicates to a therapist a serious threat to harm an identifiable person, the therapist must warn that person and the police
- b. if the therapist suspects child abuse or neglect, or abuse of a helpless adult or of an elder, a report must be made to the designated agency
- c. if a patient appears dangerous to self or others or is unable to care for him/herself, then hospitalization might be required.
For research purposes. For more information about how research data is used here at The Shyness Clinic, please see the Informed Consent Form.
To avoid harm. In order to avoid a serious threat to the health and safety of a person or the public, the clinic may provide PHI to law enforcement personnel and persons able to prevent or lessen such harm.
For health oversight activities. Information may need to be provided to assist the government when it conducts an investigation or inspection of a health care provider or organization.

Certain Uses and Disclosures Require You to Have the Opportunity to Object.

The Shyness Clinic 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 care, unless you object in whole or in part. If you indicate to us that another person is involved in your care, we will require you to give your consent by signing a written authorization prior to our disclosing any information. Please note that the opportunity to consent may be obtained retroactively in emergency situations. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described above, Shyness Clinic staff will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to prevent any future uses and disclosures (to the extent that Shyness Clinic staff has not taken any action in reliance on such authorization) of your PHI by our practice.

Your rights regarding your PHI You have the following rights with respect to your PHI:

The right to request limits on uses and disclosures of your PHI. You have the right to ask that Shyness Clinic staff limit how we use and disclose your PHI. We will consider your request, but we are not legally required to accept it. Should your requests be accepted, Shyness Clinic staff will put any limitations in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that this practice is legally required or allowed to make.
The right to choose how your PHI is sent to you. You have the right to ask that Shyness Clinic staff send information to you at an alternate address or phone number (for example, contacting you at work rather than at home). Shyness Clinic staff must agree to your request so long as they can easily provide the PHI to you in the requested format.
The right to see and obtain copies of your PHI. In most cases, you have the right to look at or get copies of your PHI on file here at the Shyness Clinic, but you must make the request in writing. If the Shyness Clinic does not have your PHI but is aware who does, you will be informed about how to obtain it.
Shyness Clinic staff will respond within 5 working days of receiving your written request. If you request a copy of your record your request may be responded to within 15 working days. Charges for copying, mailing and other clerical costs up to $16.00/hr may be incurred. It is also possible to request a summary of your records and such a request may be responded to within 10 working days. In certain situations, your request to see or obtain copies of your PHI may be denied. In those situations, you will be informed in writing as to the reasons for the denial and your rights to have the denial reviewed will be explained.
The right to obtain a list of disclosures made by The Shyness Clinic. You have the right to obtain a list of instances in which Shyness Clinic staff have disclosed your PHI. The list will not include uses nor 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 will also not include uses and disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. Shyness Clinic staff will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list you will receive will include disclosures made in the last six years unless you request a shorter time. Included in the list will be the date of disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. Such a list will be provided to you at no charge, however if you make more than one request in the same year, you will be charged a reasonable cost based fee for each additional request.
The right to correct or update your PHI. If you believe that there is a mistake in your PHI or that an important piece of information is missing, you have the right to request that the existing information be corrected or that the missing information be added. You must provide the request and your reason for the request in writing. Shyness Clinic staff will respond within 60 days upon receipt of your request to correct or update your PHI. Shyness Clinic staff may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by The Shyness Clinic, (iii) not allowed to be disclosed, or (iv) not part of our records. The written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you elect not to file a written statement of disagreement, you have the right to request that your request and our denial be attached to all future disclosures of your PHI. If your request is approved, you will be informed of the changes to your PHI and others that need to know will also be informed about the change(s) to your PHI.
The right to receive this Notice by email. You have the right to obtain a copy of this Notice by e-mail. Even if you have agreed to receive a notice via email, you also have the right to request a paper copy of it.

For more information or to file a complaint about privacy practices here at The Shyness Clinic

If you think that The Shyness Clinic may have violated your privacy rights, or if you disagree with a particular decision staff have made regarding access to your PHI, you may file a complaint with our Privacy Officer, Elaine Thomas, Psy.D 467 Hamilton Avenue, Ste 4 Palo Alto, CA 94301. She can be reached by phone at (650) 328-6115, ext 2. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Ave, S.W., Washington D.C. 20201. The Shyness Clinic will take no retaliatory action against you should you file a complaint about our privacy practices.

Effective Date of this Notice

This Notice went into effect on April 14, 2003. Revised May 7, 2003.