Notice of Privacy Practices

SW Holistic Therapy · Savannah Boyd, LMFT #156572

Effective date: [Month Day, Year]

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

Your health information is personal, and protecting it is part of my ethical and legal responsibility as your therapist. This notice explains how I may use and share your protected health information (PHI), what rights you have, and what my responsibilities are. When California law gives you more protection than federal law (HIPAA), I follow California law.

Your Rights

You have the right to:

Get a Copy of Your Records

You can ask to see or get an electronic or paper copy of your records. I'll respond within 30 days, and I may charge a reasonable, cost-based fee. In limited cases, I may deny access, for example if a licensed professional believes access would endanger you or someone else. If I do, I'll explain why in writing and tell you how to request a review. Psychotherapy notes (described below) are not part of the records you can request.

Ask Me to Correct Your Records

You can ask me to correct information you think is incorrect or incomplete. I may say no, but I'll explain why in writing within 60 days, and you can submit a statement of disagreement.

Request Confidential Communications

You can ask me to contact you in a specific way (for example, by a particular phone number or email) or at a specific address. I'll agree to all reasonable requests.

Ask Me to Limit What I Use or Share

You can ask me not to use or share certain information for treatment, payment, or operations. I'm not required to agree, and I may say no if it would affect your care. If you pay for a service fully out of pocket, you can ask me not to share information about it with your health insurer. I'll say yes unless a law requires me to share it.

Get a List of Those I've Shared Information With

You can ask for a list (accounting) of the times I've shared your health information for six years before the date you ask, who I shared it with, and why. The list won't include disclosures for treatment, payment, or operations, or ones you asked me to make. I'll provide one list a year for free and may charge a reasonable fee for additional requests within 12 months.

Get a Copy of This Notice

You can ask for a paper copy of this notice at any time, even if you agreed to receive it electronically.

Choose Someone to Act for You

If you've given someone medical power of attorney, or someone is your legal guardian, that person can exercise your rights. I'll confirm they have this authority before taking any action.

File a Complaint if You Believe Your Rights Were Violated

You can contact me using the information at the end of this notice. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:

You can also contact the California Board of Behavioral Sciences, which licenses Marriage and Family Therapists (www.bbs.ca.gov). I will not retaliate against you for filing a complaint.

Your Choices

For certain information, you can tell me your choices about what I share. If you have a clear preference, tell me, and I'll follow your instructions.

You have both the right and the choice to tell me whether to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster-relief situation

If you can't tell me your preference (for example, if you're unconscious), I may share information if I believe it's in your best interest, or when needed to lessen a serious and imminent threat to health or safety.

I never share your information in these cases unless you give me written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

Psychotherapy notes are notes I may keep separately from your clinical record to analyze the content of sessions. They receive extra protection. In almost all cases, I need your written authorization to share them.

Fundraising: I don't fundraise. If that ever changes, you'll have a clear way to opt out.

My Uses and Disclosures

I typically use or share your health information in the following ways.

Treatment

I use your information to provide therapy. I may share it with other professionals who are treating you. For clients exploring or receiving ketamine-assisted psychotherapy, this includes coordinating with your prescribing clinician ([Prescribing partner name]) about screening, safety, and your care plan.

Running My Practice (Health Care Operations)

I may use and share your information to run my practice, improve your care, and contact you when necessary. This includes using HIPAA-compliant vendors (such as an electronic health record, telehealth platform, or scheduling tool) who sign Business Associate Agreements, which legally require them to protect your information.

Billing for Services (Payment)

I may use and share your information to bill and get payment, including preparing superbills you submit to your insurer, or communicating with your health plan if you ask me to.

Other Ways I May Use or Share Your Information

I'm allowed or required to share your information in other ways, usually ones that serve the public good, such as public health and safety. I must meet the conditions of the law before sharing information for these purposes.

  • Preventing serious harm. If you communicate a serious threat of physical violence against a reasonably identifiable person, California law requires me to take reasonable steps to warn and protect that person and notify law enforcement. I may also share information to prevent or lessen a serious and imminent threat to your own safety.
  • Abuse and neglect reporting. As a mandated reporter, I must report known or reasonably suspected abuse or neglect of a child, an elder, or a dependent adult to the appropriate authorities.
  • Public health and safety. For example, preventing disease or reporting adverse reactions to medications.
  • Complying with the law. I'll share information if state or federal law requires it, including with the Department of Health and Human Services if it wants to confirm that I'm complying with privacy law.
  • Health oversight. For audits, investigations, licensure, or disciplinary actions, such as by the Board of Behavioral Sciences.
  • Lawsuits and legal actions. I may share information in response to a court or administrative order, or in response to a subpoena when the law permits. When possible, I'll notify you first so you have a chance to object. Psychotherapist-patient privilege under California law may protect your information in legal proceedings.
  • Law enforcement and government requests. When required by law. This includes requests for workers' compensation claims, specialized government functions such as military or national security, and coroners or medical examiners.
  • Research. Only with your written authorization or as permitted by law.

Substance Use Disorder Records

If I receive records from a federally assisted substance use disorder treatment program (covered by 42 CFR Part 2), those records have additional protection. They cannot be used or disclosed in any civil, criminal, administrative, or legislative proceeding against you unless you give specific written consent or a court issues an order that meets Part 2 requirements, along with a subpoena or similar legal mandate. [Attorney: confirm whether the practice receives Part 2 records and adjust this section.]

Telehealth and Electronic Communication

Sessions take place on a HIPAA-compliant video platform [name]. Standard email and text messages are not fully secure. If you choose to communicate by email or text, I'll discuss the risks with you first, and I'll keep messages brief and focused on scheduling. Please don't send detailed clinical information by email. Because sessions are virtual, I'll confirm your physical location in California at the start of each session for safety and licensing reasons.

My Responsibilities

  • I am required by law to maintain the privacy and security of your protected health information.
  • I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • I must follow the duties and privacy practices described in this notice and give you a copy of it.
  • I will not use or share your information other than as described here unless you tell me in writing that I can. If you give me permission, you can change your mind at any time by letting me know in writing.

Changes to This Notice

I can change the terms of this notice, and the changes will apply to all the information I have about you. The new notice will be available on request, at my website, and at intake.

Contact for Privacy Questions

Savannah Boyd, LMFT, Privacy Officer SW Holistic Therapy [Mailing address or PO box for privacy correspondence] savannah@swholistictherapy.com · (510) 629-0565