Kristina Antonson M.D.

Psychiatry and Psychotherapy

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 READ IT CAREFULLY

The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a Federal program that requests that all medical records and other individually identifiable health information used or disclosed by me in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, the right to understand and control how your personal health information ("PHI") is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, I prepared this explanation of how I maintain the privacy of your health information and how I may disclose your personal information.

My responsibilities:

I am required by law to protect the privacy of your health information, to provide this notice about my privacy practices and to abide by the terms of this notice.
I reserve the right to change my policies and procedures for protecting health information. When I make a significant change in how I use or disclose your health information, I will also change this notice.
Except for the purposes related to your treatment, to collect payment for my services, to perform necessary business functions, or when otherwise permitted or required by law, I will not use or disclose your health information without your authorization. You have the right to revoke your authorization at any time.

When can I legally disclose your Personal Health Information without your consent?

In order to facilitate your medical treatment. Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. For example, I may need to coordinate care with your primary care provider or your psychotherapist, and in this case I may disclose information including your diagnosis, symptoms, medications etc. I also at times seek consultation from other licensed mental health professionals. In this case, I take care to avoid identifying material such as name, specific age, and other details that could identify you.
In order to collect payment. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would include sending your insurance company a bill for your visit and verifying coverage prior to a visit.
In order to facilitate routine office operations. Health Care Operations include business aspects of running my practice. As of the current writing (10/4/15) I do not having any employees or use a billing service. However, at some point in the future, I may. In this case, my employees and/or billing service (who will be trained appropriately) will have access to a small portion of your medical information in order to do their job.
I may also be required to disclose your PHI to law enforcement (ie in response to a legitimate subpoena). In all situations, I shall do my best to assure its continued confidentiality to the extent possible

You may have the following rights with respect to your PHI.

The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you. My practice policy is not to disclose any PHI to any friend or relative except with your specific consent. The big exception to this is if I feel you pose an immediate danger to yourself or someone else. In that case, I will do whatever is necessary even if that means breaching confidentiality.
The right to reasonable requests to receive confidential communications of Protected Health Information by alternative means or at alternative locations.
The right to inspect and copy your PHI.
The right to amend your PHI.
The right to receive an accounting of disclosures of your PHI.
The right to obtain a paper copy of this notice from me upon request.
The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed.

If you have any further questions or would like additional information or an updated copy of this form, please contact me, Kristina Antonson MD, at 916-712-0578 or in writing at the address above. If you feel your privacy rights have been violated in any way, please let me know and I will take appropriate action.

You may also file a complaint to the Department of Health and Human Services at the address below. There is more information about filing a health information privacy complaint at www.HHS.gov

I will not retaliate against you for filing a complaint.

U.S. Department of Health and Human Services
Office for Civil Rights
Centralized Case Management Operations
200 Independence Ave., S.W.
Suite 515F, HHH Building
Washington, D.C. 20201