Notice of Privacy Practices

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request. We may say “no” if it would affect your care.
• If you pay for a service or health care item with your own money and no insurance, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask. This will include who we shared it with, and why.
• We will include all the disclosures except for ones about treatment, payment, and health care operations, and certain other disclosures (for example, any you asked us to make). We’ll provide one list a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

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.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights.
• You can 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/.
• We will not retaliate against you for filing a complaint.

In these cases, you have both the right and choice to tell us to:

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

If you can’t tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

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

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

How do we typically use or share your health information?

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

Treat you

We can use your health information and share it with other professionals who are treating you.
‍Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways. These are usually ways that contribute to the public good, like public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it. This includes sharing with the Department of Health and Human Services if it wants to confirm that  we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We 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 like military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

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

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

• Effective Date of this Notice: February 1, 2017
• This notice applies to:
  Two Chairs Behavioral Health Group, a Psychology Corporation
  Pacific Psychotherapy Technologies, Inc
• Please contact us to request a copy of this Notice in other languages or to get a copy in another format, such as large print or braille.

For additional information, please contact us at [email protected]

Two Chairs:

• Provides people with disabilities reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as:

• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats).

• Provides free language assistance services to people whose primary language is not English, which may include:

• Qualified interpreters
  
• Information written in other languages.

If you need reasonable modifications, appropriate auxiliary aids and services, or language assistance services, contact [email protected] you believe that Two Chairs has failed to provide these services or discriminated in another way, you can file a grievance with:
‍
Two Chairs Compliance Department
PO BOX 593, San Francisco, CA 94104-0593
Fax: (415) 360-5916
[email protected]

If you need help filing a grievance, reach out to [email protected]. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

English

ATTENTION: If you need help in your language call (415) 202-5159. Aids and services for people with disabilities, like documents in braille and large print, are also available. These services are free of charge.

عربي (Arabic)

تنبيه: إذا كنت بحاجة إلى مساعدة بلغتك، اتصل على (415)202-5159. تتوفر أيضًا مساعدات وخدمات للأشخاص ذوي الإعاقة، مثل المستندات المكتوبة بطريقة برايل والمطبوعة بحروف كبيرة. هذه الخدمات مجانية.

tanbihi: 'iidha kunt bihajat 'iilaa musaeadat bilaghatika, atasal ealaa (415) 202-5159. tatawafar aydan musaeadat wakhadamat lil'ashkhas dhawi al'iieaqati, mithl almustanadat almaktubat bitariqat brayil walmatbueat bihuruf kabiratin. hadhih alkhadamat majaaniatun.

简体中文标语 (Chinese-Simplified)

请注意：如果您需要以您的母语提供帮助，请致电 (415) 202-5159。我们另外还提供针对残疾人士的帮助和服务，例如盲文和大字体阅读，提供您方便取用。这些服务都是免费的。

Kreyòl (Creole)

ATANSYON: Si ou bezwen èd nan lang ou a, rele (415) 202-5159. Gen èd ak sèvis pou moun ki andikape, tankou dokiman an bray ak an gwo karaktè, ki disponib tou. Sèvis sa yo gratis.

Français (French)

ATTENTION : Si vous avez besoin d’aide dans votre langue, appelez le (415) 202-5159. Des aides et services pour les personnes handicapées, tels que des documents en braille et en gros caractères, sont également disponibles. Ces services sont gratuits.

Deutsch (German)

ACHTUNG: Wenn Sie Hilfe in Ihrer Sprache benötigen, rufen Sie (415) 202-5159 an. Hilfsmittel und Dienstleistungen für Menschen mit Behinderungen, wie Dokumente in Braille und Großdruck, sind ebenfalls verfügbar. Diese Dienstleistungen sind kostenlos.

ગુજરાતી (Gujarātī)

ધ્યાન: જો તમને તમારી ભાષામાં મદદની જરૂર હોય તો (415) 202-5159 પર કૉલ કરો. અપંગ લોકો માટે સહાય અને સેવાઓ, જેમ કે બ્રેઇલ અને મોટા પ્રિન્ટમાં દસ્તાવેજો, પણ ઉપલબ્ધ છે. આ સેવાઓ મફત છે.

dhyāna: Jō tamanē tamārī bhāṣāmāṁ madadanī jarūra hōya tō (415) 202-5159 para kŏla karō. Apaṅga lōkō māṭē sahāya anē sēvā'ō, jēma kē brē'ila anē mōṭā prinṭamāṁ dastāvējō, paṇa upalabdha chē. Ā sēvā'ō maphata chē.

हिंदी (Hindi)

ध्यान दें: अगर आपको अपनी भाषा में सहायता चाहिए, तो (415) 202-5159 पर कॉल करें। विकलांग लोगों के लिए ब्रेल और बड़े अक्षरों में दस्तावेज़ जैसी सहायता और सेवाएँ भी उपलब्ध हैं। ये सेवाएँ निःशुल्क हैं।

dhyaan den: agar aapako apanee bhaasha mein sahaayata chaahie, to (415) 202-5159 par kol karen. vikalaang logon ke lie brel aur bade aksharon mein dastaavez jaisee sahaayata aur sevaen bhee upalabdh hain. ye sevaen nihshulk hain.

Italiano (Italian)

ATTENZIONE: Se hai bisogno di aiuto nella tua lingua, chiama il numero (415) 202-5159. Sono disponibili anche ausili e servizi per persone con disabilità, come documenti in braille e a caratteri grandi. Questi servizi sono gratuiti.

한국어 (Korean)

유의사항: 귀하의 언어로 도움을 받고 싶으시면 (415) 202-5159 번으로 문의하십시오. 점자나 큰 활자로 된 문서와 같이 장애가 있는 분들을 위한 도움과 서비스도 이용 가능합니다. 이러한 서비스는 무료로 제공됩니다.

Français (French)

ATTENTION : Si vous avez besoin d’aide dans votre langue, appelez le (415) 202-5159. Des aides et services pour les personnes handicapées, tels que des documents en braille et en gros caractères, sont également disponibles. Ces services sont gratuits.

Polski (Polish)

UWAGA: Jeśli potrzebujesz pomocy w swoim języku, zadzwoń pod numer (415) 202-5159. Dostępne są również pomoce i usługi dla osób niepełnosprawnych, takie jak dokumenty w alfabecie Braille'a i dużym druku. Usługi te są bezpłatne.

Português (Portuguese)

ATENÇÃO: Se precisar de ajuda com o seu idioma, ligue para (415) 202-5159. Recursos e serviços para pessoas com deficiência, como documentos em braille e letras grandes, também estão disponíveis. Esses serviços são gratuitos.

Русский слоган (Russian)

ВНИМАНИЕ! Если вам нужна помощь на вашем родном языке, звоните по номеру (415) 202-5159. Также предоставляются средства и услуги для людей с ограниченными возможностями, например документы крупным шрифтом или шрифтом Брайля. Такие услуги предоставляются бесплатно.

Español (Spanish)

ATENCIÓN: si necesita ayuda en su idioma, llame al (415) 202-5159. También ofrecemos asistencia y servicios para personas con discapacidades, como documentos en braille y con letras grandes. Estos servicios son gratuitos.

Tagalog (Tagalog)

ATENSIYON: Kung kailangan mo ng tulong sa iyong wika, tumawag sa  (415) 202-5159. Mayroon ding mga tulong at serbisyo para sa mga taong may kapansanan,tulad ng mga dokumento sa braille at malaking print. Libre ang mga serbisyong ito.

Khẩu hiệu tiếng Việt (Vietnamese)

CHÚ Ý: Nếu quý vị cần trợ giúp bằng ngôn ngữ của mình, vui lòng gọi số (415) 202-5159. Chúng tôi cũng hỗ trợ và cung cấp các dịch vụ dành cho người khuyết tật, như tài liệu bằng chữ nổi Braille và chữ khổ lớn (chữ hoa). Các dịch vụ này đều miễn phí.