AnnMarie Nelson, LMFT # 97177 is a Licensed Marriage and Family Therapist in the State of California, and operates as a sole proprietorship. This practice operates as AnnMarie Nelson, LMFT, doing business as AM Nelson Counseling Services and is located at: 27201 Puerta Real, Suite 300 PMB 305 Mission Viejo, CA 92691. General contact can be made by calling the office at 949.445.0510.
As a notice to California clients, the Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of marriage and family therapists. You may contact the board online at www.bbs.ca.gov, or by calling 916.574.7830. My license can be verified through the Board of Behavioral Sciences website.
No Surprises-Right to Receive Good Faith Estimate of Expected Charges
Under California law, you have the right to receive a good faith estimate of expected charges. You may multiple your fee by the number of sessions to obtain your annual expected charges.
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.
The practice of AnnMarie Nelson, LMFT, doing business as AM Nelson Counseling Services, uses privacy and security practices and policies as part of meeting the standard of care. These practices and policies meet or exceed the current HIPAA standards of privacy and security policies. While the practice does not directly bill any insurance plan, it is deemed a basic standard of care to maintain privacy and security.
I am required by law and ethics to maintain the privacy and security of your protected health information (“PHI”). I have chosen to provide you with this Notice of Privacy Practices (“Notice”). I must abide by the terms of this Notice, and I will 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, in my office, and on my website.
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:
For your treatment. I 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.
To obtain payment for your treatment. I can use and disclose your PHI to bill and collect payment for treatment, fees, and any services provided by me to you. For example, I might send your PHI to a specific person, entity, or organization which you have designated to pay for your care. It is always my preference for you to give me a written Authorization to do so.
For health care operations. I 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.
Psychotherapy Notes. At times, I do 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:
FOR MY USE IN TREATING YOU
Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I 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, I can use and disclose your PHI without your Authorization for the following reasons:
Certain Uses and Disclosures Require You to Have the Opportunity to Object.
Disclosures to family, friends, or others. I 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:
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.
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.
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.
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.
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.
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 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.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right to 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 COMPLAIN ABOUT MY PRIVACY PRACTICES
If you think I 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:
AnnMarie Nelson, LMFT | 27201 Puerta Real, Suite 300 PMB 305 Mission Viejo, CA 92691 | 949.445.0510
You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:
I will not retaliate against you if you file a complaint about my privacy practices.
EFFECTIVE DATE OF THIS NOTICE | This notice went into effect on July 01, 2021