Nancy Nguyen, LCSW

Expanding Pathways · San Jose, California

Notice of Privacy Practices

This notice involves your privacy rights and describes how information about you may be disclosed, and how you can obtain access to this information. Please review it carefully.

I. Confidentiality

As a rule, I will disclose no information about you, or the fact that you are my patient, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, I do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing the attached general consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me.

II. Limits of confidentiality

There are some important exceptions to this rule of confidentiality, some created voluntarily by my own choice, and some required by law. If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits. I may use or disclose records or other information about you without your consent or authorization in the following circumstances:

• Emergency: If you are involved in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.
• Child abuse reporting: If I have reason to suspect that a child is abused or neglected, I am required by California law to report the matter immediately to the California Department of Social Services.
• Adult abuse reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected, or exploited, I am required by California law to immediately make a report and provide relevant information to the California Department of Welfare or Social Services.
• Health oversight: California law requires that licensed social workers report misconduct by a health care provider of their own profession. If you describe unprofessional conduct by another mental health provider, I am required to explain how to make a report. If you are yourself a health care provider, I am required by law to report to your licensing board that you are in treatment with me if I believe your condition places the public at risk.
• Court proceedings: Therapy information is privileged under state law, and I will not release records unless you provide written authorization or a judge issues a court order. If I receive a subpoena, I will notify you so you can file a motion to quash it. Protections may not apply in certain civil or criminal proceedings, or where an evaluation is court-ordered.
• Serious threat to health or safety: If you communicate a specific and immediate threat to cause serious bodily injury or death to an identifiable person, and I believe you have the intent and ability to carry it out, I am legally required to take steps to protect third parties, which may include warning the potential victim, notifying law enforcement, or seeking your hospitalization.
• Workers' compensation: If you file a workers' compensation claim, I am required by law, upon request, to submit relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
• Records of minors: California law limits the confidentiality of minors' records in certain circumstances, including parental access regardless of custody. We will discuss these in detail if I provide services to a minor.

Other uses and disclosures not covered by this notice or by applicable law will be made only with your written permission.

III. Your rights and my duties

• Right to request restrictions on certain uses and disclosures of your protected health information, submitted in writing. I am not required to agree to a requested restriction.
• Right to confidential communications by alternative means or at alternative locations, requested in writing.
• Right to an accounting of disclosures made without your consent or authorization.
• Right to inspect and copy your medical and billing records, submitted in writing. A copying/mailing fee may apply, and access to certain notes may be limited in specific circumstances.
• Right to request an amendment to information you believe is incorrect or incomplete, submitted in writing with your reasoning.
• Right to a paper copy of this notice at any time.

I reserve the right to change my policies and this notice, effective for information I already have as well as information received in the future. If you believe your privacy rights have been violated, you may file a complaint with my office in writing, or with the U.S. Department of Health and Human Services.

Acknowledgement of receipt

I have been provided a copy of Nancy Nguyen's Notice of Privacy Practices. We have discussed these policies, and I understand that I may ask questions about them at any time in the future. I consent to accept these policies as a condition of receiving mental health services.