HIPAA Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.

1. Our Legal Duties

We are required by law to maintain the privacy and security of your Protected Health Information (PHI). We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it.

We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing.

2. How We May Use and Share Your Health Information

For Treatment

We may use and share your PHI to provide, coordinate, or manage your care. For example, we may share information with other health care providers involved in your treatment, such as your primary care physician or psychiatrist, with your written authorization.

For Payment

We may use and share your PHI to bill and collect payment for the services we provide to you. For example, we may share information with your insurance company to obtain reimbursement after services are rendered, with your written authorization.

For Health Care Operations

We may use and share your PHI for practice operations, such as quality assessment, licensing, and administrative purposes. For example, we may use information to review our treatment services and evaluate staff performance.

As Required by Law

We will share information when required to do so by federal, state, or local law, including with the Department of Public Health or other authorities.

To Avert a Serious Threat to Health or Safety

We may use and share your information when necessary to prevent a serious and imminent threat to your health and safety or the health and safety of others. This may include sharing with someone able to help stop or lessen the threat.

Special Situations

We may share information in specific situations including: suspected abuse, neglect, or domestic violence (to a government authority); court orders or other judicial proceedings; law enforcement purposes; organ and tissue donation; workers' compensation; and to coroners, medical examiners, and funeral directors.

3. Your Rights Regarding Your Health Information

When it comes to your health information, you have the right to:

• Get an electronic or paper copy of your medical record — you may ask in writing to see or get a copy of your records. We will provide a copy in the format you request if it is reasonably possible.
• Ask to correct your record — you may ask us to correct information you believe is inaccurate or incomplete. We may say no to your request, but we'll tell you why in writing within 60 days.
• Request confidential communications — you may ask us to contact you in a specific way (e.g., by cell phone) or to send mail to a different address.
• Ask us to limit what we use or share — you may ask us not to use or share certain health information for treatment, payment, or operations. We are not required to agree to your request, except for out-of-pocket payments paid in full.
• Get a list of those with whom we've shared information — you may ask for a list (accounting) of the times we've shared your health information for purposes other than treatment, payment, health care operations, and certain other purposes, for up to six years prior to your request.
• Get a copy of this privacy notice — you may ask for a paper copy of this notice at any time.
• Choose someone to act for you — if you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• File a complaint if you feel we have violated your rights — you may file a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights.

4. Uses and Disclosures Requiring Your Authorization

The following uses and disclosures of your PHI will be made only with your explicit written authorization:

• Uses and disclosures of psychotherapy notes (if we maintain any separately from your medical record)
• Uses and disclosures of PHI for marketing purposes
• Disclosures that constitute a sale of your PHI

Any other uses and disclosures not described in this notice will be made only with your authorization. You may revoke an authorization at any time in writing, except to the extent we have already relied on it.

5. Our Responsibilities

• We are required by law to maintain the privacy and security of your PHI
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information
• We must follow the duties and privacy practices described in this notice and give you a copy of it
• We will not use or share your information other than as described here unless you tell us we can in writing

6. Changes to This Notice

We can change the terms of this notice at any time. The new notice will apply to all PHI we maintain. We will post the current notice in our office and on our website, and provide it to you upon request.

7. Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights. You will not be penalized or retaliated against for filing a complaint.

To file a complaint with us:
SOULFLO Therapy
Attention: Privacy Officer
7290 Navajo Road #105, San Diego, CA 92119
(619) 292-8885
nancy@soulflotherapy.com

To file a complaint with the federal government:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775
www.hhs.gov/ocr/privacy/hipaa/complaints

8. Licensed Providers

Our licensed and registered providers include:

• Nancy Phung-Smith, LMFT138181 — Founder & Clinical Supervisor
• Brittney Raymond, AMFT144473 — Registered Associate Marriage and Family Therapist
• Mai Eguchi, AMFT151333 — Registered Associate Marriage and Family Therapist
• James Bui, ASW131658 — Registered Associate Clinical Social Worker
• Jenny Vu, AMFT155099 — Registered Associate Marriage and Family Therapist
• Nan Wang, APCC 19931; AMFT156148 — Registered Associate Professional Clinical Counselor & Registered Associate Marriage and Family Therapist
• Karen Xie, AMFT 164627 exp 7/31/27 — Registered Associate Marriage and Family Therapist
• Liz Weisenburger, LPCC 23097 — Licensed Professional Clinical Counselor & Clinical Rehabilitation Specialist