Center for Mindful Psychotherapy, Inc.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Center for Mindful Psychotherapy (hereafter CMP) is required by law to maintain
the privacy and security of your protected health information (“PHI”) and to provide you
with this Notice of Privacy Practices (“Notice”). CMP must abide by the terms of this
Notice, and CMP must notify you if a breach of your unsecured PHI occurs. CMP can
change the terms of this Notice, and such changes will apply to all information I have
about you. The new Notice will be available upon request, in our office, and on our
website.
Except for the specific purposes set forth below, CMP will use and disclose your PHI
only with your written authorization (“Authorization”). It is your right to revoke such
Authorization at any time by giving CMP written notice of your revocation.
Uses (Inside Practice) and Disclosures (Outside Practice) Relating to
Treatment, Payment, or Health Care Operations Do Not Require Your Written
Consent. CMP can use and disclose your PHI without your Authorization for the
following reasons:
1. For your treatment. CMP can use and disclose your PHI to treat you, which
may include disclosing your PHI to another health care professional. For
example, if you are being treated by a physician or a psychiatrist, CMP can
disclose your PHI to him or her to help coordinate your care, although my
preference is for you to give me an Authorization to do so.
2. To obtain payment for your treatment. CMP can use and disclose your PHI
to bill and collect payment for the treatment and services provided by CMP to
you. For example, CMP might send your PHI to your insurance company to
get paid for the health care services that CMP has provided to you, although
our preference is for you to give CMP an Authorization to do so.
3. For health care operations. CMP can use and disclose your PHI for
purposes of conducting health care operations pertaining to our practice,
including contacting you when necessary. For example, CMP may need to
disclose your PHI to our attorneys to obtain advice about complying with
applicable laws.
Certain Uses and Disclosures Require Your Authorization.
1. Psychotherapy Notes. CMP does keep “psychotherapy notes” as that
term is defined in 45 CFR § 164.501, and any use or disclosure of
such notes requires your Authorization unless the use or disclosure is:

a. For our use in treating you.
b. For our use in training or supervising other mental health practitioners
to help them improve their skills in group, joint, family, or individual
counseling or therapy.
c. For our use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to
investigate o u r compliance with HIPAA.
e. Required by law, and the use or disclosure is limited to
the requirements of such law.
f. Required by law for certain health oversight activities pertaining to
the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety
of others.
2. Marketing Purposes. As a not for profit agency, CMP will not use or
disclose your PHI for marketing purposes.
3. Sale of PHI. As a not for profit agency, CMP will not sell your PHI in
the regular course of my business.
Certain Uses and Disclosures Do Not Require Your Authorization. Subject to
certain limitations in the law, CMP can use and disclose your PHI without your
Authorization for the following reasons:
1. When disclosure is required by state or federal law, and the use or
disclosure complies with and is limited to the relevant requirements of such
law.
2. For public health activities, including reporting suspected child, elder, or
dependent adult abuse, or preventing or reducing a serious threat to anyone’s
health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or
administrative order, although my preference is to obtain an Authorization
from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on my
premises.
6. To coroners or medical examiners, when such individuals are
performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health
of patients who received one form of therapy versus those who received

another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution
of military missions; protecting the President of the United States; conducting
intelligence or counter-intelligence operations; or, helping to ensure the
safety of those working within or housed in correctional institutions.
9. For workers' compensation purposes. Although our preference is to obtain
an Authorization from you, CMP may provide your PHI in order to comply
with workers' compensation laws.
10. Appointment reminders and health related benefits or services. CMP may
use and disclose your PHI to contact you to remind you that you have an
appointment with us. CMP may also use and disclose your PHI to tell you
about treatment alternatives, or other health care services or benefits that
CMP offers.
Certain Uses and Disclosures Require You to Have the Opportunity to Object.
1. Disclosures to family, friends, or others. CMP may provide your PHI to a
family member, friend, or other person that you indicate is involved in your
care or the payment for your health care, unless you object in whole or in
part. The opportunity to consent may be obtained retroactively in emergency
situations.
YOUR RIGHTS YOUR REGARDING YOUR PHI
You have the following rights with respect to your PHI:
1. The Right to Request Limits on Uses and Disclosures of Your PHI.
You have the right to ask CMP not to use or disclose certain PHI for
treatment, payment, or health care operations purposes. CMP is not
required to agree to your request, and CMP may say “no” if CMP believes
it would affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid
for In Full. You have the right to request restrictions on disclosures of your
PHI to health plans for payment or health care operations purposes if the
PHI pertains solely to a health care item or a health care service that you
have paid for out-of-pocket in full.
3. The Right to Choose How I Send PHI to You. You have the right to ask
CMP to contact you in a specific way (for example, home or office phone) or
to send mail to a different address, and CMP will agree to all reasonable
requests.
4. The Right to See and Get Copies of Your PHI. Other than
“psychotherapy notes,” you have the right to get an electronic or paper
copy of your medical record and other information that CMP has about you.

CMP will provide you with a copy of your record, or a summary of it, if you
agree to receive a summary, within 30 days of receiving your written request,
and CMP may charge a reasonable, cost based fee for doing so.
5. The Right to Get a List of the Disclosures I Have Made.
You have the right to request a list of instances in which CMP has disclosed
your PHI for purposes other than treatment, payment, or health care
operations, or for which you provided me with an Authorization.
CMP will respond to your request for an accounting of disclosures within 60
days of receiving your request. The list CMP will give you will include
disclosures made in the last six years unless you request a shorter time.
CMP will provide the list to you at no charge, but if you make more than one
request in the same year, CMP will charge you a reasonable cost based fee
for each additional request.
6. The Right to Correct or Update Your PHI. If you believe that there
is a mistake in your PHI, or that a piece of important information is
missing from your PHI, you have the right to request that CMP
correct the existing information or add the missing information.
CMP may say “no” to your request, but CMP will tell you why in
writing within 60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You
have the right get a paper copy of this Notice, and you have the right
to get a copy of this notice by e-mail. And, even if you have agreed
to receive this Notice via e-mail, you also have the right to request a
paper copy of it.
HOW TO COMPLAIN ABOUT CMP PRIVACY PRACTICES
If you think CMP may have violated your privacy rights, you may file a complaint with me,
as the Privacy Officer for CMP, and my address and phone number are:
Scott Balderson, Director CMP, 533A Castro Street, San Francisco, CA 94114;
(415) 255-6181
You can also file a complaint with the U.S. Department of Health and Human Services
Office for Civil Rights by:
1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C.
20201;
2. Calling 1-877-696-6775; or,
3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.
I will not retaliate against you if you file a complaint about my privacy practices.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on September 20, 2013.

This is a copy of the Center for Mindful Psychotherapy’s Privacy Practices that is posted as a legal requirement by the Bureau of Behavioral Health of the State of California.