Privacy Practices
&
Good Faith Estimate

Your Information. Your Rights. Our Responsibilities.

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This notice of privacy practices describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

Please know that this notice is a summary only, and that applicable law places requirements on us, and limiters/expanders on the issues discussed in this notice (including our uses/disclosures), that may not be obvious. For example, HIPAA’s definitions of “marketing” and “sales” and “breach” and “healthcare operations”, and the related restrictions, are technical, include exceptions, and do not apply to all situations you may personally consider to be within those definitions. So, for instance, if HIPAA allows, we may use/disclose your information for healthcare operations purposes that you may personally believe are marketing or sales, without your authorization. This notice is not intended to be more restrictive than applicable law, unless explicitly noted.

 

Your Rights

With your health information, you have certain rights. This section generally explains your rights and some of our responsibilities to help you.

 

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 do not have to agree to your request, and we may say “no” if it would affect your care.

•       If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for payment or our operations with your health insurer. We will say “yes” unless a law requires/allows 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 before the date you ask, who we shared with, and why.

•       We will include all the disclosures except for those about treatment, payment, and healthcare operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free, but will charge a reasonable, cost-based fee if you request another 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 believe your rights have been violated.

•       You can complain if you feel we have violated your rights by contacting us using the information on page 1.

•       You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.

•       We will not retaliate against you for filing a complaint.

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Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Let us know what you want us to do, and we’ll follow your instructions.

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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

If you cannot 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

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In the case of fundraising:

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

 

Our Uses and Disclosures

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 your health information 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 provide your information to your health insurance plan so it can 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 – usually in ways that contribute to the public good, such as public health and research. We must meet many conditions in the law before we can share your information for these purposes.

Help with public health and safety issues. We can share health information about you for certain situations, such as: (i) preventing disease; (ii) helping with product recalls; (iii) reporting adverse reactions to medications; (iv) reporting suspected abuse, neglect, or domestic violence; or (v) 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, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests. We can share your health information 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: (i) for workers’ compensation claims; (ii) for law enforcement purposes or with a law enforcement official; (iii) with health oversight agencies for activities authorized by law; or (iv) for special government functions such as 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 (only if efforts have been made to notify you of the request (which may include written notice) or to obtain an order protecting the requested information).

 

Other Ways We Can Use/Disclose Information. Applicable law allows for additional uses and disclosures which are not all enumerated and explained above, and we will use/disclose information in any manner permitted by applicable law, including, without limitation, uses and disclosures: made at your request; for appointment reminders; to recommend treatment alternatives and healthcare related products and services; limited data sets in certain circumstances; to avert a serious threat to health or safety; for certain public health and safety issues; to third party business associates who assist us; to coroners, medical examiners, and funeral directors if death occurs; to aggregate data and de-identify data (at which point it is not subject to HIPAA); sharing within an Organized Healthcare Arrangement we may participate in, within accountable care organizations, regional health information organizations, blue button project, or other health information exchanges (in these situations, there may be an “opt-out” right or other rights you may have); and uses and disclosures that are incidental to other permitted uses and disclosures.

 

Our Responsibilities

•       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. 

•       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. 

Nondiscrimination

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Hermosillo Family Therapy, Inc., complies with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently based on race, color, national origin, age, disability, sex, or other legally enumerated protected classes. We, as necessary, provide free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, written information in other formats (large print, audio, accessible electronic formats, other formats), language services to people whose primary language is not English (e.g., qualified interpreters, information written in different languages). If you need these services, contact Dr. Desiree Hermosillo. If you believe that Hermosillo Family Therapy, Inc., has failed to provide these services or discriminated in another way based on a protected class, you can file a grievance with: Dr. Desiree Hermosillo, email: Desiree@hermosillofamilytherapy.com.

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You can file a grievance in person or by email. If you need help filing a grievance, Desiree Hermosillo is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically via the Office for Civil Rights Complaint Portal, https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at the following: 
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). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

 

Changes to the Terms of this Notice

We can change this notice, and the changes will apply to all information we have about you. The new notice will be available upon request at our office and on our website.

Other

•       We are advising you in this notice that, if you email or text us health information, or request that we provide you with information in these or similar mediums, that these are unsecure mediums for transmitting information and that there is some risk to using these mediums. Information transmitted in these ways is more likely to be intercepted by unauthorized third parties than more secure transmission channels. If you want to communicate with us in these mediums, you are accepting the risks we have notified you of, and you agree that we are not responsible for unauthorized access to such medical information while it is in transmission to you based on your request or after the information is delivered to you.

•       Besides the potentially applicable Federal HIPAA law, there are other federal or state health information privacy laws. In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosures described in this notice. These laws may, for instance, occasionally require your specific written permission before disclosures of certain particularly sensitive information (such as mental health, psychotherapy, genetic testing, drug/alcohol/substance abuse, pregnancy, or HIV/AIDS/ARC information) in circumstances that the HIPAA regulations would permit disclosure without your permission. We comply with all applicable laws that impose stricter nondisclosure requirements or apply to highly sensitive/protected information. For example, regarding mental health records, Hermosillo Family Therapy, Inc. complies with the Lanterman-Petris-Short Act to the extent applicable. Please note, however, that psychotherapy notes are narrowly defined under HIPAA and do not include all mental health care records.

•       This notice applies to any other entity/member of an organized healthcare arrangement in which we might participate, including, without limitation, our affiliated entities, practices that we manage, psychologists, and therapists.    

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Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.
Under the law, health care providers must give patients who don’t have certain types of health care coverage, or who are not using them, an estimate of their bill for health care items and services before those items or services are provided.

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• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the healthcare provider or facility gives you a Good Faith Estimate in writing within 3business days after you ask.

• If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate and the bill.

 

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

 

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entities’ compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.