HIPAA Disclosure

Notice of Privacy Practices


The Federal Health Insurance Portability and Accountability Act (HIPAA) requires mental health professionals to issue this official Notice of Privacy Practices. This notice describes how information about you is protected, the circumstances under which it may be used or disclosed and how you may gain access to this information. Please review it carefully. For psychotherapy to be beneficial, it is important that you feel free to speak about personal matters, secure in the knowledge that the information you share will remain confidential. You have the right to the confidentiality of your medical and psychological information, and this practice is required by law to maintain the privacy of that information. This practice is required to abide by the terms of the Notice of Privacy Practices currently in effect, and to provide notice of its legal duties and privacy practices with respect to protected health and psychological information. If you have any questions about this Notice, please contact the Privacy Officer at this practice.

Who Will Follow This Notice

Any health care professional authorized to enter information into your medical record, all employees, staff, and other personnel at this practice who may need access to your information must abide by this Notice. All subsidiaries, business associates (e.g., a billing service), sites and locations of this practice may share medical information with each other for treatment, payment purposes or health care operations described in this Notice. Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be shared.

Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your Protected Health Information (PHI), for treatment, payment, and health care operations purposes. The following should help clarify these terms:

  • PHI refers to information in your health record that could identify you. For example, it may include your name, the fact you are receiving treatment here, and other basic information pertaining to your treatment.
  • Use applies only to activities within my office and practice group, such as sharing, employing, applying, utilizing, and analyzing information that identifies you.
  • Disclosure applies to activities outside of my office or practice group, such as releasing, transferring, or providing access to information about you to other parties.
  • Authorization is your written permission to disclose confidential health information. All authorizations to disclose must be made on a specific and required form.
  • Treatment is when we provide, coordinate, or manage your health care and other services related to your health care. For example, with your written authorization we may provide your information to your physician to ensure the physician has the necessary information to diagnose or treat you.
  • Payment Your PHI may be used, as needed, in activities related to obtaining payment for your health care services. This may include the use of a billing service or providing you documentation of your care so that you may obtain reimbursement from your insurer. Health Care Operations are activities that relate to the performance and operation of my practice. We may use or disclose, as needed, your protected health information in support of business activities. For example, when we review an administrative assistant’s performance, we may need to review what that employee has documented in your record.

Written Authorizations to Release PHI

Any other uses and disclosures of your PHI beyond those listed above will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke your authorization at any time, in writing.

Uses and Disclosures without Authorization

  • Child Abuse – If we have reasonable cause to believe a child may be abused or neglected, we must report this belief to the appropriate authorities.
  • Adult and Domestic Abuse – If we have reason to believe that an individual such as an elderly or disabled person protected by state law has been abused, neglected, or financially exploited, we must report this to the appropriate authorities.
  • Health Oversight Activities – we may disclose your PHI to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions. If a client files a complaint or lawsuit against me, we may disclose relevant information regarding that patient in order to defend myself.
  • Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information by any party about your treatment and the records thereof, such information is privileged under state law, and is not to be released without a court order. Information about all other psychological services (e.g., psychological evaluation) is also privileged and cannot be released without your authorization or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You must be informed in advance if this is the case.
  • Serious Threat to Health or Safety – If you communicate to me a specific threat of imminent harm against another individual or if we believe that there is clear, imminent risk of injury being inflicted against another individual, we may make disclosures that we believe are necessary to protect that individual from harm. If we believe that you present an imminent, serious risk of injury or death to yourself, we may make disclosures we consider necessary to protect you from harm.
  • Worker's Compensation – we may disclose PHI regarding you as authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

Special Authorizations

Certain categories of information have extra protections by law, and thus require special written authorizations for disclosures.

  • Psychotherapy Notes – we will obtain a special authorization before releasing your Psychotherapy Notes. "Psychotherapy Notes" are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your record. These notes are given a greater degree of protection than PHI.
  • HIV Information – Special legal protections apply to HIV/AIDS related information. We will obtain a special written authorization from you before releasing information related to HIV/AIDS.
  • Alcohol and Drug Use Information – Special legal protections apply to information related to alcohol and drug use and treatment. We will obtain a special written authorization from you before releasing information related to alcohol and/or drug use/treatment. You may revoke all such authorizations (of PHI, Psychotherapy Notes, HIV information, and/or Alcohol and Drug Use Information) at any time, provided each revocation is in writing, signed by you, and signed by a witness. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

Patient's Rights and Psychologist's/Psychotherapist’s Duties Patient's Rights

  • Right to Request Restrictions – You have the right to request restrictions on certain uses/disclosures of PHI. However, we are not required to agree to the request.
  • Right to Receive Confidential Communications by Alternative Means – You have the right to request and receive confidential communications by alternative means and locations. (For example, you may not want a family member to know that you are seeing me. On your request, we will send your bills to another address.)
  • Right to Inspect and Copy – You have the right to inspect or obtain a copy of PHI in my records as these records are maintained. In such cases we will discuss with you the process involved.
  • Right to Amend – You have the right to request an amendment of PHI for as long as it is maintained in the record. We may deny your request. If so, we will discuss with you the details of the amendment process.
  • Right to an Accounting – You generally have the right to receive an accounting of all disclosures of PHI. We can discuss with you the details of the accounting process.
  • Right to a Paper Copy – You have the right to obtain a paper copy of the Notice of Privacy Practices from me upon request.

Psychologist's/Psychotherapist’s Duties:

  • We are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
  • We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
  • If we revise my policies and procedures, we will notify you at our next session, or by mail at the address you provided me.


If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at this practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or discriminated against for filing a complaint. If you have any questions about this Notice, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me:

Soni Kim, Psy.D.
Privacy Officer
Crossroads Institute for Psychotherapy and Assessment
2601 Airport Drive Suite 135
Torrance, CA 90505

Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on May 21, 2003 and remain so unless new notice provisions effective for all protected health information are enacted accordingly.