LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 502.01 Notice of Privacy Practices
 
  PROCEDURES
 
  1. LACDMH Responsibilities to Provide Clients with Adequate Notice of LACDMH  Uses and Disclosures of Protected Health Information: (HIPAA Public Law 104-191; 45 CFR Sections 164.502 and 164.520)
 
  1. Provide a printed or electronic copy of LACDMH Notice of Privacy Practices to all clients at “first contact” and every three (3) years after the first date of receipt.
     
  2. Be prepared to consider alternative means of communicating LACDMH Notice of Privacy Practices to “special” populations, such as individuals who cannot read or who have limited English proficiency.
     
  3. Use LACDMH approved forms to establish client acknowledgement of Receipt of LACDMH Notice of Privacy Practices (Attachment 2) for audit purposes.
     
  4. Document in the client’s medical record any failure to obtain a client’s signed or initialed acknowledgement including the reason for not being able to obtain the client’s signed or initialed acknowledgement.
     
  5. In an emergency treatment situation any delay in offering the LACDMH Notice of Privacy Practices must be documented and pursued at a reasonably practicable time after the emergency treatment situation is over.
     
  6. Clinical staff admitting or completing an intake, either face to face or over the telephone, shall be prepared to review uses and disclosures of a client’s PHI that do not require an authorization from the client (listed below). (HIPAA Law Section 164.512)
 
  1. Treatment, payment and healthcare operations
  • Treatment means
     
  • Payment means
     
  • Healthcare operations means
  1. Required by law
     
  2. Research
     
  3. Workers’ Compensation
     
  4. Public health activities
     
  5. Health oversight activities
     
  6. Lawsuits and disputes
     
  7. Law enforcement
     
  8. Specialized government functions
 
  1. Clinical staff admitting or completing an intake, either face to face or on the telephone shall be prepared to review uses and disclosures of a client’s PHI that do require the client’s authorization (listed below). (HIPAA Law Section 164.508)
 
  1. Disclosing information to a family member, parent, or any other person identified by the client.
     
  2. Disclosing PHI to other organizations or agencies that are not considered part of the client’s treatment team or responsible for coordination of their care.
     
  3.  Disclosing PHI to another agency when a client changes his/her place of residence.
 
  1. LACDMH Responsibilities to Provide Clients with Adequate Notice of Their Rights Regarding Paper and Electronic Records of Their Protected Health  Information: (HIPAA Public Law 104-191; 45 CFR Parts 160-164 Sections 164.522, 164.524, 164.526, and 162.528)
 
  1. Clinical staff admitting or completing an intake, either face to face or on the telephone, must discuss with the client their right to restrict uses and disclosures of their PHI and specify how and where confidential communications shall take place. Use the following LACDMH approved forms for this procedure.
  • Request for Restriction on the Manner/Method of Confidential Communications
     
  • Client Request to Restrict Access to Their PHI
     
  • Response to Request for Special Restriction on Use or Disclosure of PHI
     
  • Client Request to Terminate Special Restrictions
 
  1. Clinical staff admitting or completing an intake, either face to face first contact or on the telephone first contact, must discuss with the client their right to access their PHI. Use the following LACDMH approved forms for this procedure. (LACDMH Policy No. 501.01, Clients’ Right to Access Protected Health Information and Confidential Data)
  • Client Request to Inspect and/or Copy PHI.
     
  • Response to Client Request to Inspect and/or Copy PHI.
 
  1.  Clinical staff admitting or completing an intake, either face to face first contact or on the telephone first contact, must discuss with the client their right to amend their PHI. Use the following LACDMH approved forms for this procedure.
  • Client Request to Amend PHI.
     
  • Response to Client Request to Amend PHI.
     
  • Statement of Client Disagreement/Request to Include Amendment to PHI.
     
  • Notification of Client Amendment to PHI Sent to All Agencies.
 
  1. Clinical staff admitting or completing an intake, either face to face first contact or on the telephone first contact with documentation, must discuss with the client their right to receive an accounting of all uses and disclosures of their PHI that have occurred after April 14, 2003. Exceptions to this rule are disclosures for treatment, payment, and healthcare operations and disclosure authorized by the client. Use the following LACDMH approved forms for this procedure.
  • Client Request for Accounting of Disclosures of PHI.
     
  • Response to Client Request for Accounting of Disclosure of PHI.