NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED, AND SAFEGUARDED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 

I. WHO IS SUBJECT TO THIS NOTICE

All affiliates of Heart 2 Heart Behavioral Health.

 

II. OUR RESPONSIBILITY

The confidentiality of your personal health information is very important to us. Your health information includes records that we create and obtain when we provide your care, such as a record of your symptoms, examination and test results, diagnoses, treatments, and referrals for further care. It also includes bills, insurance claims, or other payment information that we maintain related to your care.

This Notice describes how we handle your health information and your rights regarding this information. Generally speaking, we are required to:

• Maintain the privacy of your health information as required by law.

• Provide you with this Notice of our duties and privacy practices regarding the health information we collect and maintain about you.

• Follow the terms of our Notice currently in effect.

 

III. CONTACT INFORMATION

After reviewing this Notice, if you need further information or wish to contact us for any reason regarding the handling of your health information, please direct any communications to the following:

Heart 2 Heart Behavioral Health

1 Avenue of the Palms Suite 307

San Francisco, California 94130
Phone: (602) 555-1234
Email: info@cchaw.com

 

IV. USES AND DISCLOSURES OF INFORMATION

Under federal and California state law, we are permitted to use and disclose personal health information without authorization for treatment, payment, and health care operations. However, ethical standards and state law may require us to obtain your express consent before making certain disclosures.

Healthcare providers of Heart 2 Heart Behavioral Health may also share health information with each other, as necessary to carry out treatment, payment, or health care operations relating to the provision of patient care.

 

V. OTHER USES AND DISCLOSURES

In addition to uses and disclosures related to treatment, payment, and health care operations, we may also use and disclose your personal health information without authorization for the following additional purposes:

 

Abuse, Neglect, or Domestic Violence
As required or permitted by law, we may disclose health information about you to a state or federal agency to report suspected abuse, neglect, or domestic violence.

 

Appointment Reminders and Other Health Services
We may use or disclose your information to remind you of appointments or inform you about treatment alternatives, case management, or care coordination.

 

Business Associates
We may share information with business associates who perform services on our behalf, such as billing or IT management, under confidentiality agreements.

 

Communicable Diseases
We may disclose information to someone at risk of contracting or spreading a disease, as authorized by law.

 

Communications with Family and Friends
We may share information with those involved in your care or payment for care, using professional judgment to determine what is in your best interest.

 

Coroners, Medical Examiners, and Funeral Directors
We may provide necessary health information to these entities to carry out their duties.

 

Disaster Relief
We may share information with agencies like the Red Cross to assist in disaster relief efforts.

 

Food and Drug Administration (FDA)
We may disclose health information to the FDA regarding adverse events or product issues.

 

Health Oversight
We may disclose information for authorized oversight activities such as audits or investigations.

 

Judicial or Administrative Proceedings
We may disclose health information in response to lawful court or administrative orders.

 

Law Enforcement
We may disclose information to law enforcement as required by law or for locating individuals.

 

Minors & Parents
We may disclose minor health information to parents or guardians under certain legal circumstances.

 

Notification
We may notify family or representatives of your location, condition, or death, when appropriate.

 

Organ and Tissue Donation
We may disclose information to facilitate organ or tissue donation.

 

Personal Representative
We may disclose information to a person legally authorized to make health decisions for you.

 

Public Health Activities & Safety
We may share information to report disease, injury, or to prevent a serious public threat.

 

Required By Law
We may disclose information as required by federal, state, or local law.

 

Research
We may disclose limited health information for approved research purposes.

 

Specialized Government Functions
We may disclose information for authorized military, national security, or correctional purposes.

 

Workers' Compensation
We may disclose information to comply with workers' compensation laws.

 

VI. PSYCHOTHERAPY NOTES

Psychotherapy notes are kept separately from your medical record and are afforded special protection under law. These notes may only be disclosed with your written authorization, except in rare cases (e.g., to prevent harm or report abuse). You cannot be required to authorize release of psychotherapy notes to receive treatment or insurance benefits.

 

VII. YOUR HEALTH INFORMATION RIGHTS

You have the right to:

• Request restrictions on certain uses or disclosures (though we are not required to agree).

• Request confidential communication methods (e.g., alternate addresses or phone numbers).

• Review or obtain a copy of your health records.

• Request an amendment to your health information.

• Request a list (accounting) of disclosures of your health information.

• Request a paper copy of this Notice.

To exercise these rights, please submit your written request to our contact listed in Section III.

 

VIII. TO REQUEST INFORMATION OR FILE A COMPLAINT

If you believe your privacy rights have been violated, you may file a complaint with us or with government authorities.

 

To file a complaint with us:
Heart 2 Heart Behavioral Health

1 Avenue of the Palms Suite 307

San Francisco, California 94130
Phone: (602) 555-1234
Email: info@cchaw.com

 

To file a complaint with the U.S. Department of Health & Human Services (HHS):
Office for Civil Rights
U.S. Department of Health & Human Services
200 Independence Avenue, S.W., Room 509F, HHH Building
Washington, D.C. 20201
Phone: 1-800-368-1019
Email: OCRprivacy@hhs.gov

 

To file a complaint with the Arizona Office of Human Rights:
Division of Behavioral Health Services
150 N. 18th Ave #210
Phoenix, AZ 85007
Phone: (602) 364-4558

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To file a complaint in Oregon:

Oregon Bureau of Labor and Industries (BOLI) — Civil Rights Division
800 NE Oregon St., Suite 1045
Portland, OR 97232
Phone: 971-245-3844
Email: BOLI_help@boli.oregon.gov
BOLI enforces state civil rights laws and investigates discrimination complaints. You can also file online or by mail; they protect individuals from retaliation for filing a complaint. Oregon

You may also contact the Oregon Health Authority, Equity and Inclusion Division for discrimination complaints related to state health programs:
421 SW Oak Street, Suite 750, Portland, OR 97204
Phone: 971-673-3420
Email: oha.publiccivilrights@odhsoha.oregon.gov Oregon

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To file a complaint in Michigan:

Michigan Department of Civil Rights (MDCR)
3054 West Grand Boulevard, Suite 3-600
Detroit, MI 48202
Phone: 313-456-3700
Toll-Free: 800-482-3604
Michigan Relay: 711

The MDCR investigates complaints of unlawful discrimination under state law (race, age, sex, disability, etc.). You may file in person, by phone, by mail, online, or through virtual intake options. The department enforces anti-retaliation protections when you file a complaint. Michigan.gov

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To file a complaint in New Mexico:

New Mexico Human Rights Bureau — Department of Workforce Solutions
2600 Cerrillos Rd
Santa Fe, NM 87505
Phone: 1-800-566-9471 (toll-free in NM) or 505-827-6838
Email: Human.RightsInfo@dws.nm.gov

The Human Rights Bureau accepts and investigates discrimination complaints (employment, housing, credit, public accommodations) under the New Mexico Human Rights Act. Initial inquiries can lead to filing a formal charge; there are protections against retaliation for filing a complaint. DWS New Mexico

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To file a complaint in California:

California Civil Rights Department (CRD)
2218 Kausen Drive, Suite 100
Elk Grove, CA 95758
Phone: 800-884-1684 (voice)
TDD: 800-700-2320
Email: contact.center@calcivilrights.ca.gov

The CRD (formerly the Department of Fair Employment and Housing) enforces California’s civil rights laws covering employment, housing, public accommodations, and more. You can contact them by phone, mail, or email to file a discrimination complaint. The agency enforces protections against retaliation for filing a complaint. ca.gov

 

We will not retaliate against you for filing a complaint.

 

IX. REVISIONS TO THIS NOTICE

We reserve the right to amend this Notice. Revisions will apply to all health information we maintain, including past records. If we make significant changes, we will post an updated Notice in our office and on our website.

 

X. EFFECTIVE DATE

November 1, 2025