NOTICE OF PRIVACY PRACTICES
Jill Sumiyasu, LMFT · A Better Life with Jill
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I 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 currently in effect, and I must notify you if a breach of your unsecured PHI occurs. I can change the terms of this Notice, and the new terms will apply to all PHI I have about you. The new Notice will be available upon request, in my office, and on my website at jillstherapy.com.
Uses and Disclosures That Do Not Require Your Written Authorization
Except for the specific purposes set forth below, I will use and disclose your PHI only with your written authorization ("Authorization"). You have the right to revoke such Authorization at any time by giving me written notice of your revocation, except to the extent that I have already acted in reliance on it.
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 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 the treatment and services I provide to you. For example, I might send your PHI to your insurance company to get paid for the health care services I have provided to you, although my preference is for you to give me an 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.
Uses and Disclosures That Require Your Written Authorization
Psychotherapy Notes
I keep "psychotherapy notes" as that term is defined in 45 CFR § 164.501. Most uses and disclosures of psychotherapy notes require your written Authorization. Authorization is not required when the use or disclosure is:
For my use in treating you;
For my use in training or supervising mental health practitioners to help them improve their counseling or therapy skills;
For my use in defending myself in a legal proceeding instituted by you;
For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA;
Required by law, where the use or disclosure is limited to the requirements of such law;
Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes;
Required by a coroner who is performing duties authorized by law; or
Required to help avert a serious threat to the health or safety of others.
Marketing
Most uses and disclosures of PHI for marketing purposes require your written Authorization. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI
Most disclosures that constitute a sale of PHI require your written Authorization. As a psychotherapist, I will not sell your PHI.
Other Uses and Disclosures
Other uses and disclosures of PHI not covered by this Notice or the laws that apply to me will be made only with your written Authorization.
Uses and Disclosures That 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:
When required by state or federal law, where the use or disclosure complies with and is limited to the relevant requirements of such law.
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.
For health oversight activities, including audits and investigations.
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.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, when permitted by law and subject to specific protections.
For specialized government functions, including ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or helping to ensure the safety of those working within or housed in correctional institutions.
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.
For appointment reminders and health-related benefits or services. I may use and disclose your PHI to remind you of an appointment, or to tell you about treatment alternatives or other health care services or benefits I offer.
Disclosures You Have the Opportunity to Object To
I may provide your PHI to a family member, friend, or other person you indicate is involved in your care or in payment for your health care, unless you object. The opportunity to consent may be obtained retroactively in emergency situations.
Your Rights 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. 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 that I not disclose your PHI to a health plan for payment or health care operations purposes if the PHI pertains solely to a health care item or 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, at home or at the office) or to send communications to a different address. 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 I have about you.
I will allow you to inspect your record within five (5) working days after receiving your written request, and I will provide you with a copy or summary of your record within fifteen (15) days of receiving your written request, in accordance with California Health & Safety Code § 123110. I may charge a reasonable, cost-based fee for copying.
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 an Authorization. I will respond to your request within 60 days of receiving it. 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 important information is missing, 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 a paper copy of this Notice, and you have the right to receive a copy of this Notice by email. Even if you have agreed to receive this Notice by email, you also have the right to request a paper copy of it.
The Right to Be Notified of a Breach. You have the right to be notified following a breach of your unsecured PHI.
How to Complain About My Privacy Practices
If you believe I have violated your privacy rights, you may file a complaint with me, as the Privacy Officer for my practice, at:
Jill Sumiyasu, LMFT, Privacy Officer
236 W. Mountain Street, Suite 202E
Pasadena, CA 91103
Phone: (626) 720-4677
Email: jill@jillstherapy.com
You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:
Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;
Calling 1-877-696-6775; or
In addition, California residents may file a complaint with the California Attorney General or the California Department of Consumer Affairs Board of Behavioral Sciences.
I will not retaliate against you for filing a complaint about my privacy practices.
Effective Date
This Notice is effective as of May 7, 2026.