The Feeling Space, A Marriage and Family Therapy Corporation

720 Wilshire Blvd. Suite 204

Santa Monica, CA 90401

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU

CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting

health information about you. I create a record of the care and services you receive from me. I need this record

to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the

records of your care generated by this mental health care practice. This notice will tell you about the ways in

which I may use and disclose health information about you. I also describe your rights to the health information

I keep about you, and describe certain obligations I have regarding the use and disclosure of your health

information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• I can change the terms of this Notice, and such changes will apply to all information I have about you. The

new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category

of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a

category will be listed. However, all of the ways I am permitted to use and disclose information will fall within

one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care

providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s

personal health information without the patient’s written authorization, to carry out the health care provider’s

own treatment, payment or health care operations. I may also disclose your protected health information for the

treatment activities of any health care provider. This too can be done without your written authorization. For

example, if a clinician were to consult with another licensed health care provider about your condition, we

would be permitted to use and disclose your personal health information, which is otherwise confidential, in

order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and

other health care providers need access to the full record and/or full and complete information in order to

provide quality care. The word “treatment” includes, among other things, the coordination and management of

health care providers with a third party, consultations between health care providers and referrals of a patient

for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court

or administrative order. I may also disclose health information about your child in response to a subpoena,

discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have

been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: