Privacy Policy


Privacy is a foundation of a relationship between patient and the therapist. We take all possible measures to assure that your data are protected. As your therapist I am taking very active role in maintaining the security and safety of information you provide us.

Under the Health Insurance Portability and Accountability Act (“HIPAA”), which is a federal law, I am required to maintain the privacy of your protected health information and provide you with notice of my legal duties and privacy practices with respect to such protected health information.

How I May Use or Disclose Your Health Information

I may use or disclose your protected health information, for treatment, payment, and health care operations purposes with your authorization. To help clarify these terms, here are some definitions:

Protected Health Information (PHI) refers to information in your health record that could identify
Treatment is when I provide, coordinate or manage your health care and other services related to your health
Payment is when I obtain reimbursement for your health
Health Care Operations are activities that relate to the performance and operation of my
Use applies only to my activities such as applying, utilizing, examining, and analyzing information that identifies
Disclosure applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other
Authorization is your written permission to disclose confidential mental health All authorizations to disclose must be on a specific legally required form.
The following categories describe different ways that I may use and disclose PHI. 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 these categories.

Uses and Disclosures Requiring Authorization

For treatment. I may use or disclose your PHI to provide, coordinate or manage health care and treatment. For example, I may consult with another health care provider, such as your family physician, your neurologist, your psychologist or another psychiatrist. With your written authorization, I may also disclose information about you to other people who may be involved in your care, such as family members.

For payment. I may need to disclose PHI about you to determine eligibility or coverage or so that treatment and services you receive from me may be billed and payment may be collected from you, an insurance com- pany, or a third party. For example, I may need to disclose information about the services you receive from me so your health plan will pay me or reimburse you for the services. Your health plan provider may be told about a treatment you are going to receive to determine whether your plan will cover the treatment. Again, I will obtain written authorization to disclose this information.

Business Associates. I contract with service providers – called business associates – to perform various func- tions on my behalf. For example, I may contract with a service provider to perform the administrative func- tions necessary to submit your medical claims. To perform these functions or to provide the services, business associates will receive, create, maintain, use, or disclose PHI, but only after I and the business asso- ciate agree in writing to contract terms requiring the business associate to appropriately safeguard your information.

For health care operations. I may use and disclose PHI about you for office operations. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. These uses and disclosures are necessary to run my office and make sure that all patients receive quality care.

Appointment reminders. I may use and disclose medical information to contact you as a reminder that you have an appointment with me. For example, a message may be left on your answering machine. You have the right to be contacted by another method if you prefer. However, you must inform me in writing about your preference and I must agree to that request. If I agree to your request, I am bound to abide by it.

Additional Disclosures Without Authorization

I may use or disclose information related to your care without your consent or authorization in the follow- ing circumstances:

Serious Threat to Health or Safety. I may disclose your confidential information to protect you or others from a serious threat of harm by you. I may communicate relevant information concerning this to the poten- tial victim, appropriate family members, or law enforcement or other appropriate authorities.

Child Abuse. If I know, or have reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver or other person responsible for the child’s welfare, the law requires that I report such knowledge or suspicion to Santa Clara County Child Protective Services or to an appropri- ate law enforcement agency.

Adult and Domestic Abuse. If I know, or have reasonable cause to suspect, that a vulnerable adult (dependent or elderly) has been or is being abused, neglected, or exploited, I am required by law to immediately report such knowledge or suspicion to Santa Clara County Adult Protective Services or to an appropriate law enforcement agency.

Health Oversight. The California Board of Psychology has the power, when necessary, to subpoena relevant records should I be the focus of an inquiry.

Judicial or Administrative Proceedings. If you are involved in a court proceeding, and a request is made for information about the professional services that I have provided you and/or the records thereof, such infor mation is privileged under state law, and I must not release this information without your written authori- zation, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

Other uses and disclosures of PHI not covered by this notice or applicable laws will be made only with your written permission. If you provide the me permission to use or disclose medical information about you, you may revoke this permission, in writing, at any time. If you revoke your permission, I will no longer use or disclose medical information about you for the reasons covered by your written authorization. You under- stand that you may not revoke an authorization to the extent that I have relied on that authorization; or if the authorization was obtained as a condition of obtaining insurance coverage, and law provides the insurer the right to contest the claim under the policy.

Your Rights Related to HIPAA and Protected Health Information (PHI)

As my patient, you have the following rights regarding PHI that is maintained about you.

Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of PHI about you. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing. In your request, you must tell me 1) what information you want to limit; 2) whether you want to limit our use, disclosure, or both; and 3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations. You have the right to request and receive confidential communications of PHI by alternative means and at alter- native locations. (For example, you may not want a family member to know that you are being seen by me. Upon your written and approved request, messages for you can be left by another method). To request con- fidential communications, you must make your request in writing. I will not ask you the reason for your request. I will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to inspect and copy. You have the right to inspect and copy PHI that may be used to make decisions about your care as long as this information is maintained in the record. To inspect and copy information that may be used to make decisions about you, you must submit your request in writing. If you request a copy of the information, I may charge a fee for the cost of copying, mailing, or other supplies associated with your request. I may deny your request to inspect and copy in certain limited circumstances.

Right to Amend. You have the right to request an amendment of your PHI for as long as this information is maintained in the record. On your request, I will discuss with you the details information of the amendment process.

Right to an Accounting. You generally have the right to receive an accounting of disclosures of your PHI for which you have neither provided consent nor authorization. On your request, I will discuss with you the details of the accounting process.


Mountain View Psychiatry & TMS
525 South Drive, Suite 207
Mountain View, CA 94040
Phone: 650-231-4490
Fax: 650.969.3309
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