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We protect the privacy of our patients’ health information and adhere to a set of internal policies established to conform to the requirements of state and federal laws. This privacy statement explains your rights, our legal duties, and our privacy practices. 


Your Health Information




We collect, use, and disclose information about you in providing, coordinating, or managing your treatment and wellness activities. We may provide referring physicians, other providers, and other alternative practitioners information about your treatment when they are appropriately involved with the treatment process. 


For Payment: We may use and disclose information about you in managing your medical file in order to secure treatment authorization, to confirm insurance coverage, for medical billing, and receiving payments for medical care through your health plan or other similar entities. We may also provide information to a doctor’s office, hospital, other health care providers or health plans, to confirm your eligibility for benefits, medical diagnosis, treatment, and other medically necessary information, in order to provide appropriate services and receive payment. 


For Health Care Operations: We may use and disclose your protected health information (“PHI”) for our operations. For example, we may use information about you to review the quality of care and services you receive; to provide you with medical file management or for the coordination of medical services such as between treating therapists or between doctor and therapist. 

As Permitted or Required by Law: Information about you may be used or disclosed to regulatory agencies, such as during audits, licensure, or other proceedings; for administrative or judicial proceedings; to public health authorities; or to law enforcement officials, such as to comply with a court order or subpoena. 


Authorization: Other uses and disclosures of PHI will be made only with your written permission, unless otherwise permitted or required by law. You may revoke this authorization, at any time, in writing. We will then stop using your information for that purpose. However, if we have already used your information based on your authorization, you cannot take back your agreement for those past situations. 


Your Rights 


Under regulations that have been in effect since April 14, 2003, you will have additional rights over your health information. Under these rules, you will have the right to: 


  • Send us a written request to see or get a copy of information we have about you or amend your personal information that you believe is incomplete or inaccurate. If we did not create the information, we will refer you to the source, such as your physician or hospital. 


  • Request additional restrictions on uses and disclosures of your health information. We are not required to agree to these requests. 


  • Request that we communicate with you about medical matters using reasonable alternative means or at an alternative address if communications to your home address could endanger you. 


  • Receive an accounting of our disclosures of your medical information, except when those disclosures are made for treatment, payment, or health care operations, or the law otherwise restricts the accounting. We are not required to give you a list of disclosures made before April 14, 2003. 




If you believe your privacy rights have been violated, you have the right to file a complaint with us, or with the federal government. You will not be penalized for filing a complaint. 

Copies and Changes 


You have the right to receive an additional copy of this notice at any time. We reserve the right to revise this notice. A revised notice will be effective for information we already have about you as well as any information we may receive in the future. We are required by law to comply with whatever privacy notice is currently in effect. We will communicate any changes to our notice through direct mail. 


Contact Information 


If you want to exercise your rights under this notice or if you wish to communicate to us about privacy issues or to file a complaint with us, please contact us at (510) 788-1299. 

Declaration of Privacy of Health Information 


All medical records and other individually identifiable health information used or disclosed by a covered entity in any form, whether electronically, on paper, or orally, are covered by the US Department of Health and Human Services (HHS), and are covered by HIPAA (Health Insurance Portability and Accountability Act of 1996). 


I authorize that the results of any assessments or records given to me may be used in completing evaluations, assessments, treatment plans, progress reports, summary reports, discharge summary reports and medical billing and reimbursement. I understand that such reports will only report aggregated data and will only be used for healthcare purposes, such as third-party payment, physician or other authorized healthcare provide treatment, or progress reports. I understand I can restrict the uses and disclosures of my medical information. I understand that I have the right to file a formal complaint with a covered provider or health plan or HHS about violations regarding my health and medical records or information. This release is and shall be binding upon my heirs, assigns, executors, and administrators.

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