Notice of Privacy Practices

Please read the Notice of Privacy Practices. (Click here to expand.)

Notice of Privacy Practices

Effective Date: April 22nd, 2025

This notice explains how your health information may be used and disclosed and how you can access it. Please review it carefully.

1. Your Rights

You have the right to:

Get a copy of your records
Request corrections to your records
Request confidential communication (e.g., phone only, no voicemail)
Ask us to limit what we share
Get a list of people we’ve shared your info with
File a complaint if you believe your privacy rights were violated

2. Our Responsibilities

We are required to:

Maintain the privacy of your health information
Provide you with this notice of our legal duties and privacy practices
Follow the terms of this notice
Notify you if a breach compromises your information

3. How We Use and Share Your Information

We may use or share your health information:

For treatment – to provide, coordinate, or manage your care
For payment – to bill for services provided
For health care operations – for practice management and quality improvement
With your written authorization – for any use not listed above
As required by law – such as reporting abuse or court orders

4. Electronic Communication

If you authorize us, we may use email or text messaging to confirm appointments or send brief messages. These methods are not fully secure. We will ask for your consent separately before using these tools.

5. State-Specific Protections

California:
Under the California Confidentiality of Medical Information Act (CMIA), your mental health records may be more strictly protected than under HIPAA. We will comply with both HIPAA and CMIA.

Oregon:
Oregon law may require your specific authorization before disclosing mental health or psychotherapy notes. We follow the more protective rule where applicable.

6. Changes to This Notice

We may update this notice at any time. The revised notice will be available in our office and on our website. Changes apply to all health information we have about you.

7. Questions or Complaints

If you have questions or concerns about this notice, or believe your rights have been violated, you may contact:

Privacy Officer
Azizeh Rezayian
Azizeh@siliconvalleymarriagecounseling.com

You can also file a complaint with the U.S. Department of Health and Human Services at www.hhs.gov/ocr/privacy/hipaa/complaints.

We will not retaliate against you for filing a complaint.

Please Read and Complete the Following

Before your first session, please read the Notice of Privacy Practices above. This explains how your health information may be used and protected.

Then, fill out the form below to:

Confirm you’ve received the notice
Indicate how you prefer to communicate
Provide your signature and consent

If you have any questions, feel free to contact us before signing.

HIPAA Acknowledgment and Communication Consent Form

Including for use in California and Oregon

First Name

Last Name

Date of birth.

1. Acknowledgment of Receipt of HIPAA Notice of Privacy Practices

I acknowledge that I have received a copy of the therapist’s Notice of Privacy Practices. This notice describes how my health information may be used and disclosed, and how I can access this information under the Health Insurance Portability and Accountability Act (HIPAA).

I have read and understood the Notice of Privacy Practices.

I was offered a copy but declined.

2. State-Specific Privacy Disclosures

California Clients:

I understand that my therapist also complies with the California Confidentiality of Medical Information Act (CMIA), which offers additional protections for my personal health information, including mental health information.

Oregon Clients:

I understand that Oregon law may provide additional privacy protections for mental health records, and that disclosures are limited to those permitted by state and federal law.

3. Electronic Communication Consent

I understand that my therapist may use email, text messaging, or other electronic methods to communicate with me for scheduling or administrative purposes.

I acknowledge the following:

These methods may not be fully secure or HIPAA-compliant.
There is a risk of unintended disclosure if messages are intercepted or accessed by unauthorized parties.
I may revoke my consent in writing at any time.

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Email communications

I consent to communication via email at:

Text message communication.

I consent to communication via text message at:

Phone/Mobile

Decline

I do not wish to be contacted via email or text.

4. Signature

By writing my name as a signature below, I acknowledge and accept the above:

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Client signature

Date