Terms & Policies

CANCELLATION POLICY:

Scheduled appointment times are reserved specifically for you. I do have a strict 48-hour appointment cancellation policy, in which I reserve the right to charge a full fee for missed appointments, canceled and/or rescheduled appointments that are not within a 48-hour period notice.

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.  

I, Yvette Nava, LMFT, am required by law to maintain the privacy and security of your protected  health information (“PHI”) and to provide you with this Notice of Privacy Practices (“Notice”). I must  abide by the terms of this Notice, and I must notify you if a breach of your unsecured PHI occurs. 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, and in my office.  

Except for the specific purposes set forth below, I will use and disclose your PHI only with your  written authorization (“Authorization”). It is your right to revoke such Authorization at any time by  giving me written notice of your revocation.  

Uses (Inside Practice) and Disclosures (Outside Practice) Relating to Treatment, Payment, or  Health Care Operations Do Not Require Your Written Consent. I can use and disclose your PHI  without your Authorization for the following reasons:  

1. For your treatment. Yvette Nava, MS, LMFT can use and disclose your PHI to treat you, which  may include disclosing your PHI to another health care professional. For example, if you are  being treated by a physician or a psychiatrist, I can disclose your PHI to him or her to help  coordinate your care, although my preference is for you to give me an Authorization to do so.  

2. To obtain payment for your treatment. Yvette Nava, MS, LMFT can use and disclose your PHI to  bill and collect payment for the treatment and services provided by me to you. For example, I  might send your PHI to your insurance company to get paid for the health care services that I  have provided to you, although my preference is for you to give me an Authorization to do so.  

3. For health care operations. Yvette Nava, MS, LMFT can use and disclose your PHI for purposes  of conducting health care operations pertaining to my practice, including contacting you when  necessary. For example, I may need to disclose your PHI to my attorney to obtain advice about  complying with applicable laws. 

Certain Uses and Disclosures Require Your Authorization.  

1. Psychotherapy Notes. Yvette Nava, MS, LMFT does keep “psychotherapy notes” as that  term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your  Authorization unless the use or disclosure is: 

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a. For my use in treating you. 

b. For my use in training or supervising other mental health practitioners to help them  improve their skills in group, joint, family, or individual counseling or therapy.  

c. For my use in defending myself in legal proceedings instituted by you.  

d. For use by the Secretary of Health and Human Services to investigate my compliance  with HIPAA.  

e. Required by law, and the use or disclosure is limited to the requirements of such law.  

f. Required by law for certain health oversight activities pertaining to the originator of the  psychotherapy notes.  

g. Required by a coroner who is performing duties authorized by law.  

h. Required to help avert a serious threat to the health and safety of others. 

2. Marketing Purposes. As a psychotherapist, Yvette Nava, MS, LMFT will not use or disclose  your PHI for marketing purposes.  

3. Sale of PHI. As a psychotherapist, Yvette Nava, MS, LMFT will not sell your PHI in the regular  course of my business.  

Certain Uses and Disclosures Do Not Require Your Authorization.  

Subject to certain limitations in the law, Yvette Nava, MS, LMFT can use and disclose your PHI  without your Authorization for the following reasons:  

1. When disclosure is required by state or federal law, and the use or disclosure complies with  and is limited to the relevant requirements of such law.  

2. For public health activities, including reporting suspected child, elder, or dependent adult  abuse, or preventing or reducing a serious threat to anyone’s health or safety.  

3. For health oversight activities, including audits and investigations.  

4. For judicial and administrative proceedings, including responding to a court or  administrative order, although my preference is to obtain an Authorization from you before  doing so.  

5. For law enforcement purposes, including reporting crimes occurring on my premises.  

6. To coroners or medical examiners, when such individuals are performing duties authorized  by law.  

7. For research purposes, including studying and comparing the mental health of patients who  received one form of therapy versus those who received another form of therapy for the  same condition.  

8. Specialized government functions, including, ensuring the proper execution of military  missions; protecting the President of the United States; conducting intelligence or counter-

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intelligence operations; or, helping to ensure the safety of those working within or housed  in correctional institutions.  

9. For workers' compensation purposes. Although my preference is to obtain an Authorization  from you, I may provide your PHI in order to comply with workers' compensation laws.  

10. Appointment reminders and health related benefits or services. I may use and disclose your  PHI to contact you to remind you that you have an appointment with me. I may also use and  disclose your PHI to tell you about treatment alternatives, or other health care services or  benefits that I offer.  

Certain Uses and Disclosures Require You to Have the Opportunity to Object.  

1. Disclosures to family, friends, or others.  

Yvette Nava, MS, LMFT may provide your PHI to a family member, friend, or other person that  you indicate is involved in your care or the payment for your health care, unless you object in  whole or in part. The opportunity to consent may be obtained retroactively in emergency  situations.  

YOUR RIGHTS YOUR REGARDING YOUR PHI  

You have the following rights with respect to your PHI:  

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me  not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I  am not required to agree to your request, and I may say “no” if I believe it would affect your  health care.  

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the  right to request restrictions on disclosures of your PHI to health plans for payment or health  care operations purposes if the PHI pertains solely to a health care item or a health care service  that you have paid for out-of-pocket in full.  

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a  specific way (for example, home or office phone) or to send mail to a different address, and I  will agree to all reasonable requests.  

4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the  right to get an electronic or paper copy of your medical record and other information that I  have about you. I will provide you with a copy of your record, or a summary of it, if you agree to  receive a summary, within 30 days of receiving your written request, and I may charge a  reasonable, cost based fee for doing so.  

5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of  instances in which I have disclosed your PHI for purposes other than treatment, payment, or  health care operations, or for which you provided me with an Authorization. I will respond to  your request for an accounting of disclosures within 60 days of receiving your request. The list I  will give you will include disclosures made in the last six years unless you request a shorter time.  I will provide the list to you at no charge, but if you make more than one request in the same  year, I will charge you a reasonable cost based fee for each additional request.  

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or  that a piece of important information is missing from your PHI, you have the right to request 

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that I correct the existing information or add the missing information. I may say “no” to your  request, but I will tell you why in writing within 60 days of receiving your request.  

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy  of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you  have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of  it.  

HOW TO MAKE A COMPLAINT ABOUT MY PRIVACY PRACTICES  

If you think Yvette Nava, MS, LMFT may have violated your privacy rights, you may file a complaint  with me, as the Privacy Officer for my practice, and my address and phone number are:  

Yvette Nava LMFT 
4000 W. Magnolia Blvd, Suite AG 
Burbank, Ca 91505 
213.293.7252 

You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil  Rights by:  

1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201; 
2. Calling 1-877-696-6775; or,  
3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.  

Yvette Nava, MS, LMFT, will not retaliate against you if you file a complaint about her privacy  practices. EFFECTIVE DATE OF THIS NOTICE This notice went into effect on March 17, 2017. 

PLEASE RETAIN THIS SECTION FOR YOURSELF

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Good Faith Estimate Notice:

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. 

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.  

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. 

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. 

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

 For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.