HIPAA Privacy Notice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Through the Sea Marriage and Family Counseling Inc. (“the Practice”) has a legal duty to safeguard your Protected Health Information (PHI).

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Our Legal Duty to Protect Your PHI

The Practice is required by law to protect the privacy of your PHI. PHI includes information that may identify you and relates to:

• Your past, present, or future physical or mental health

• The care you receive

• Payment for your care

We are required to provide this notice explaining:

• How your PHI may be used and disclosed

• Your rights regarding your PHI

• Our legal obligations concerning your information

We will follow the privacy practices described in this notice. We reserve the right to change these practices at any time. Any changes will apply to all PHI we maintain.
 

How We May Use and Disclose Your PHI

Uses and Disclosures That Do Not Require Written Consent

1. For Treatment

We may share your PHI with other licensed healthcare providers involved in your care (e.g., psychiatrists, physicians) to coordinate treatment.

2. For Payment

We may use or disclose your PHI to bill and collect payment for services. This may include sharing information with:

• Insurance companies

• Health plans

• Billing or claims processing companies

3. For Healthcare Operations

We may use PHI for practice operations such as:

• Quality improvement

• Staff supervision

• Legal and accounting compliance

4. Emergency Situations

If you require emergency treatment and are unable to consent, we may disclose necessary information until consent can be obtained.

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Other Situations Where Consent Is Not Required

We may disclose PHI without your authorization when:

• Required by federal, state, or local law

• Ordered by a court or administrative proceeding

• Reporting abuse or neglect

• Conducting public health activities

• Participating in health oversight activities

• Supporting approved research (under specific conditions)

• Preventing serious harm to you or others

• Complying with workers’ compensation laws

• Performing specific government functions (e.g., national security)

We may also use PHI to:

• Send appointment reminders

• Provide information about treatment alternatives or services
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Disclosures Where You Have the Opportunity to Object Sharing

with Family or Others Involved in Your Care

We may share relevant PHI with family members or others involved in your care unless you object.

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Uses Requiring Written Authorization

For any uses or disclosures not described above, we will obtain your written authorization.

You may revoke authorization in writing at any time (except where action has already been taken based on that authorization).

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Your Rights Regarding Your PHI

1. Right to Request Restrictions

You may request limits on how we use or disclose your PHI. We will consider your request, but we are not legally required to agree.

2. Right to Confidential Communications

You may request that we contact you at an alternative address or by alternate means (e.g., email instead of mail). We will accommodate reasonable requests.

3. Right to Access and Copies

You have the right to review and obtain copies of your PHI (in writing).

• We will respond within 30 days.

• A fee of up to $0.25 per page may apply.

• We may provide a summary if agreed upon in advance.

• Certain requests may be denied with a written explanation.

4. Right to an Accounting of Disclosures

You may request a list of disclosures made in the past six years (excluding treatment, payment, and healthcare operations).

• We will respond within 60 days.

• One list per year is free; additional requests may incur a fee.

5. Right to Amend Records

If you believe your PHI is incorrect or incomplete, you may request an amendment in writing.

We will respond within 60 days. If denied, you will receive a written explanation and may submit a statement of disagreement.

6. Right to Receive This Notice Electronically

You may request this notice via email and may also request a paper copy at any time.
 

Dual Relationships Policy

A dual relationship occurs when a counselor interacts with a client outside the therapeutic role (e.g., shared community, business, or faith involvement).

Not all dual relationships are unethical or avoidable. However:

• They must not impair objectivity or clinical judgment.

• They must not be exploitative.

• A therapist will never publicly acknowledge working with you without your permission.

If you feel a dual relationship becomes uncomfortable or interferes with therapy, please inform your therapist immediately.
 

Potential Dual Relationship Disclosure

Samantha Pane, President and sole owner of the Practice, is a member of New Hope Community Church of West Covina (“New Hope”). At times, other New Hope members may be employed by the Practice.

If you also participate in the New Hope community:

• Employees will maintain strict client confidentiality.

• Therapy is only conducted during scheduled sessions.

• Church interactions are not considered therapy and are not protected by clinical confidentiality.

• You may request limits on PHI disclosures involving New Hope members.

• If desired, you may sign a Release of Information to allow consultation between church leadership and the Practice.

All limits will be documented in writing and honored except in emergency situations.

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How to File a Complaint

If you believe your privacy rights have been violated, you may file a complaint with:

Through the Sea Marriage and Family Counseling Inc.
Phone: 626-489-9144
Email: info@thruthesea.com

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You may also file a complaint with:

Secretary of the U.S. Department of Health and Human Services
200 Independence Avenue SW
Washington, D.C. 20201

We will not retaliate against you for filing a complaint.

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Effective Date

This notice became effective on August 16, 2023.