Privacy Notice

Zurita & Associates, LLC

Licensed Mental Health Professional · Bilingual Teletherapy Services

(505) 600-5056 · support@zuritaandassociates.com · zuritaandassociates.com

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 REVIEW IT CAREFULLY.

Effective Date: [Month Day, Year]

1. OUR LEGAL DUTY

Zurita & Associates, LLC is required by law to maintain the privacy of your protected health information (PHI), to provide you with notice of our legal duties and privacy practices with respect to your PHI, and to notify you following a breach of unsecured PHI. We are required to abide by the terms of this Notice currently in effect.

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in our practice and on our website. You may request a copy at any time.

2. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION

The following categories describe the ways we may use and disclose your PHI without your written authorization:

Treatment

We may use and disclose your PHI to provide, coordinate, or manage your mental health treatment. For example, we may share information with other treating providers (with your consent where required) to coordinate your care.

Payment

We may use and disclose your PHI to obtain payment for the services we provide. For example, we may submit billing information to your insurance company or health plan.

Health Care Operations

We may use and disclose your PHI for our health care operations, including quality assessment, training, accreditation, licensing, and business management activities.

Required by Law

We will disclose your PHI when required to do so by federal, state, or local law, including in response to a court order or valid subpoena.

Public Health Activities

We may disclose your PHI to public health authorities authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability.

Abuse or Neglect Reporting

We are mandated reporters. We may disclose your PHI to a government authority authorized by law to receive reports of child abuse, elder abuse, or neglect, or domestic violence, as required or permitted by law.

Serious Threats to Health or Safety

We may use or disclose your PHI when necessary to prevent a serious and imminent threat to your health or safety or the health or safety of others. In this case, we would only disclose to someone reasonably able to prevent or lessen the threat.

Judicial and Administrative Proceedings

We may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process.

Law Enforcement

We may release PHI for law enforcement purposes as required by law or in response to a court order, warrant, or subpoena issued by a judicial officer.

Decedents

We may disclose PHI to a coroner or medical examiner as permitted or required by law.

Business Associates

We may share your PHI with third-party "business associates" (such as billing services or electronic health record platforms) who perform services on our behalf. These associates are required by contract and law to protect your information.

Workers' Compensation

We may disclose your PHI to comply with workers' compensation laws and other similar programs.

3. USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION

The following uses and disclosures of your PHI will be made only with your written authorization, unless otherwise required by law:

• Most uses and disclosures of psychotherapy notes

• Uses and disclosures of PHI for marketing purposes

• Disclosures that constitute a sale of PHI

• Other uses and disclosures not described in this Notice

You may revoke an authorization at any time in writing, except to the extent we have already taken action in reliance on it.

4. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

You have the following rights regarding your PHI:

Right to Access

You have the right to inspect and obtain a copy of your PHI in our records. We may charge a reasonable, cost-based fee for copies. Requests must be submitted in writing. 

Right to Amend

You have the right to request that we amend your PHI if you believe it is incorrect or incomplete. We may deny your request if we did not create the information or if we believe the information is accurate. All requests and any denial must be in writing.

Right to an Accounting of Disclosures

You have the right to receive a list of certain disclosures we have made of your PHI in the six years prior to the date of your request. This right does not include disclosures made for treatment, payment, or health care operations, or disclosures made with your authorization.

Right to Request Restrictions

You have the right to request restrictions on how we use or disclose your PHI for treatment, payment, or health care operations. We are not required to agree to your requested restriction, except when you request we not disclose PHI to your health plan and you have paid for the service in full out-of-pocket.

Right to Request Confidential Communications

You have the right to request that we contact you in a specific way or at a specific location (e.g., only by email, only at a certain phone number). We will accommodate reasonable requests.

Right to a Paper Copy of This Notice

You have the right to receive a paper copy of this Notice at any time, even if you have agreed to receive it electronically. You may request a copy from our office.

Right to Notification of Breach

You have the right to be notified in the event of a breach of your unsecured PHI. We will notify you without unreasonable delay and no later than 60 days following the discovery of a breach.

5. TELEHEALTH-SPECIFIC PRIVACY PRACTICES

Zurita & Associates provides services via HIPAA-compliant telehealth platforms. When participating in telehealth sessions, please be aware of the following:

• Sessions are conducted over encrypted, HIPAA-compliant video platforms.

• You are responsible for ensuring your environment is private during sessions.

• We do not record sessions without your explicit written consent.

• Electronic communications (email, text) may not be fully secure; we encourage use of our secure portal for sensitive communications.

• We use electronic health record (EHR) systems that comply with HIPAA security standards.

6. HOW TO EXERCISE YOUR RIGHTS OR SUBMIT A COMPLAINT

To exercise any of your rights described above, or to file a complaint if you believe your privacy rights have been violated, please contact us:

Practice: Zurita & Associates, LLC

Provider: Ruben Zurita, Licensed Mental Health Professional

Phone: (505) 600-5056

Email: support@zuritaandassociates.com

Website: zuritaandassociates.com

You also have the right to file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:

HHS OCR: 200 Independence Avenue, S.W., Washington, D.C. 20201

Phone: 1-877-696-6775

Website: www.hhs.gov/ocr/privacy/hipaa/complaints

We will not retaliate against you for filing a complaint.

7. QUESTIONS

If you have any questions about this Notice or our privacy practices, please contact us at (505) 600-5056 or support@zuritaandassociates.com. We are happy to assist in English or Spanish.

CLIENT ACKNOWLEDGMENT OF RECEIPT

By signing below, I acknowledge that I have received or been offered a copy of Zurita & Associates, LLC's Notice of Privacy Practices.

Client /   Guardian Signature

_____________________________________________________

Printed   Name

_____________________________________________________

Date   _______________________________

Date of   Birth  ________________________

Zurita & Associates, LLC · Notice of Privacy Practices · Effective [Date] · Page 1 of 1