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

Who Does This Notice Apply to?

Harbor Psychiatry & Mental Health and its staff.

Our Responsibility to You Regarding Your Medical Information

We understand that medical information about you is personal. We are committed to protecting the privacy of your medical information. In order to comply with certain legal requirements, we are required to:

  • Keep your medical information private.
  • Provide you with a copy of this notice.
  • Follow the terms of this notice.
  • Notify you if we are unable to agree to a restriction that you have requested.
  • Accommodate your reasonable requests to communicate

your medical information by alternative means or at alternative locations.

  • Notify you following a breach of your unsecured medical information, as required by law.

How We May Use and Disclose Medical Information

About You

We may disclose information when you request us to do so, but we may require you to make the request in writing.


We may use and disclose medical information about you for your treatment. For example, a doctor treating you for a psychiatric condition may need to know if you have diabetes because diabetes may affect your treatment. We may also disclose medical information about you to other people, places, and entities not directly associated with Harbor Psychiatry & Mental Health, but who may be involved in your medical care. For example, we may give your physician access to your medical information to assist your physician in treating you.


We may use and disclose medical information about you to obtain payment. For example, we may give your health plan information about a psychiatric treatment you received so your health plan will pay us or reimburse you for that treatment.

Health Care Operations

We may use and disclose medical information about you to support our health care operations. For example, we may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you.

How Will My Information Be Used or Disclosed?

  • Appointment Reminders: We may use your medical information to contact you to remind you of scheduled


  • Treatment Alternatives: We may use and disclose medical information about you to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
  • Health-Related Products or Services: We may use and disclose your medical information to tell you about our health-related products or services that may be of interest to you.
  • Fundraising Activities: We may use your medical information to contact you to solicit support for certain fundraising activities

related to our operations. You will have an opportunity to opt-out of receiving such communications.

  • Family and Friends: We may release medical information about you to a family member, friend, or any other person involved in your medical care. We may also give information to

those you identify as responsible for payment of your care.

  • Health Information Exchange: We may participate in one or more health information exchanges (HIEs) and may electronically share your medical information for treatment, payment, and healthcare operations purposes with other participants in the HIEs. HIEs allow your health care providers to efficiently access and use medical information necessary for your treatment and other lawful purposes. The inclusion of your medical information in an HIE is voluntary and subject to your right to opt-out. If you do not opt-out of this exchange of information, we may provide your medical information in accordance with applicable law to the HIEs in which we participate.


We may use or disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give out medical information about you without your prior authorization for the following purposes:

  • Research: We may use and disclose medical information about you for research purposes. All research projects are subject to a special approval process through an appropriate


  • Required by Law: We may disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances or in response to valid judicial or administrative orders.
  • Public Health: We may disclose your medical information for public health activities. These disclosures generally include the following:

– to public health authorities to prevent or control disease, injury, or disability;

– to public health agencies, or other authorized entities, as permitted by state law, that maintains registries of certain information, such as immunization registries, for purposes of conducting public health surveillance, public health investigations, and public health interventions.

– to report births and deaths.

– to report the abuse or neglect of children, elders, and dependent adults.

– to notify you of recalls of products you may be using.

– to notify a person who may have been exposed to a disease

or may be at risk for contracting or spreading a disease or condition;

– to notify the appropriate government authority if we believe a competent adult patient has been the victim of abuse, neglect, or domestic violence (we will only make this disclosure if you agree or when required by law).

  • To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
  • Law Enforcement: We may disclose medical information about you to law enforcement officials upon their request:

– in response to a court order, subpoena, warrant, investigative demand, or other similar processes;

– to help identify or locate a suspect, fugitive, material witness, or missing person;

– about the victim of a crime if, under certain limited circumstances, we are unable to obtain the victim’s agreement;

– about a death we believe may be the result of criminal conduct;

– about criminal conduct occurring on our premises;

– in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

  • Health Oversight: We may disclose your medical information to health oversight agencies for purposes of legally authorized health oversight activities, such as audits and investigations

necessary for oversight of the health care system and government benefit programs.

  • Business Associates: There are some services provided through contracts that we have with business associates. We may provide your medical information to them in order to coordinate your care and for purposes of health care operations. A company that bills insurance companies on our

behalf is also our business associate, and we may provide your medical information to such a company so the company can help us obtain payment for the health care services we provide. To protect your medical information we require our business associates to appropriately safeguard your

information through a written agreement.

  • Notification: We may use or disclose your information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of

your location and general condition.

  • Funeral Directors, Medical Examiners, and Coroners: We may disclose medical information to funeral directors, coroners or medical examiners consistent with applicable law in order

for them to carry out their duties.

  • Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful processes by

someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.

  • Organ and Tissue Donation: Consistent with applicable law, we may disclose medical information to organ procurement organizations or other entities for the purpose of tissue donation and transplant.
  • Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
  • National Security: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
  • Multidisciplinary Personnel Teams: We may disclose medical information to a multidisciplinary personnel team relevant to the protection, identification, management, or treatment of (i) an abused child and the child’s parents, or (ii) elder abuse and neglect.
  • Food and Drug Administration (FDA): We may disclose certain medical information to the FDA relative to reporting adverse events.
  • Workers’ Compensation: We may disclose medical information necessary to comply with laws relating to workers’

compensation or other similar programs established by law.

  • Correctional Institutions: Should you be an inmate of a correctional institution, we may disclose medical information necessary for your health and the health and safety of other individuals to the institution or its agents.
  • Organized Health Care Arrangement: If we participate in an Organized Health Care Arrangement (OHCA) with certain other health care providers, we may share medical information with them as necessary to carry out treatment, payment, and health care operations. For example, your medical information may be shared across the OHCA in order to assess quality, effectiveness, and cost of care.
  • Special Categories of Information: In some circumstances, your medical information may be subject to restrictions that may limit or preclude some uses or disclosures described in this notice. For example, there are special restrictions on the use or disclosure of certain types of medical information (e.g., HIV test results, mental health records, and alcohol and substance abuse treatment records). Government health benefit programs may also limit the disclosure of beneficiary

information for purposes unrelated to the program and the care provided to the beneficiary.

Other Uses Or Disclosures Of Medical Information

In any other situation not covered by this notice, we will ask you for your written authorization before using or disclosing medical information about you. Specific examples of uses and disclosures requiring your authorization include: (i) most uses and disclosures of psychotherapy notes (private notes of a mental health professional kept separately from a medical record); (ii) subject to limited exceptions, uses, and disclosures of your medical information for marketing purposes; and (iii)

disclosures that constitute the sale of your medical information. If you authorize us to use or disclose your medical information, you can later revoke that authorization by notifying us in writing of your decision, except to the extent that we have taken action in reliance on your authorization.

Your Rights Regarding Medical Information About You

You have the following rights regarding medical information we maintain about you:

  • To request in writing* a restriction on certain uses or disclosures of your medical information for treatment, payment or health care operations (e.g., a restriction on who may access your medical information). Although we will consider your request, we are not legally required to agree to a requested restriction, except we must agree to your written request that we restrict a disclosure of information to a health plan if the information relates solely to an item or service for which you have paid out of pocket in full. We are required to abide by such a request, unless we are required

by law to make the disclosure. It is your responsibility to notify any other providers about this restriction.

  • To obtain a paper copy of this notice upon request, even if you have agreed to receive this notice electronically.
  • To inspect and obtain a copy of your medical information, in most cases. If you request a copy (paper or electronic), we may charge you a reasonable, cost-based fee.
  • To request in writing* an amendment to your records if you believe the information in your record is incorrect or important information is missing. We could deny your request to amend a record if the information was not created by us, is not maintained by us, or if we determine the record is accurate. You may appeal, in writing, a decision by us not to amend your record. Even if we deny your request for amendment, you have the right to submit a written addendum with respect to any item or statement in your record you believe is incomplete or incorrect.
  • To obtain an accounting of disclosures stating who and where your medical information has been disclosed for purposes other than treatment, payment, health care operations or where you specifically authorized a use or disclosure in the past six (6) years. The request must be in

writing* and state the time period desired for the accounting. After the first request, there may be a charge for additional requests made within a twelve (12) month period.

  • To request that medical information about you be communicated to you in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

*All written requests or appeals should be submitted to the address below.

Changes to this Notice

We reserve the right to change this notice at any time. We have the right to make the revised notice effective for any medical information we already have as well as any information we receive in the future. If we make a material change to this notice, we will post the revised notice at our location where you receive services and on our website and make the revised notice available upon request.


If you have any questions or would like additional information, or if you believe your privacy rights have been violated, you can contact us:

Harbor Psychiatry & Mental Health

4631 Teller, Suite 100

Newport Beach CA 92660

(949) 887-7187

You may also file a complaint with the U.S. Department of Health and Human Services Office of Civil Rights, 200 Independence Avenue, S. W., Washington, DC 20201. Filing a complaint will not negatively affect the treatment or coverage that you receive.