HIPAA Notice of Privacy Practices

Telegraph Psychology Collective / North Berkeley Counseling Collective HIPAA Notice of Privacy Practices

Notice of Privacy Practices

Effective date of this notice: This notice went into effect on September 1, 2026.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice is provided by your treating clinician, an independently licensed clinician affiliated with Telegraph Psychology Collective PC, doing business as North Berkeley Counseling Collective, together with Telegraph Psychology Collective PC. In this notice, “the Entity” refers to your treating clinician and Telegraph Psychology Collective PC together. This notice applies to the health records of the care you receive from your treating clinician.

If you have questions or concerns, please contact:

Security Officer: Danielle Kassouf, PsyD
Address: Telegraph Psychology Collective PC (DBA North Berkeley Counseling Collective), 264 Arlington Ave, Suite 3, Kensington, CA 94707
Telephone: 510-224-5591
Security Email: hello@drdaniellekassouf.com

I. The Entity’s Pledge Regarding Health Information

The Entity understands that health information about you and your health care is personal, and is committed to protecting it. The Entity creates a record of the care and services you receive. This record is needed to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the Entity. It describes the ways in which the Entity may use and disclose health information about you, your rights regarding the health information the Entity keeps about you, and certain obligations the Entity has regarding the use and disclosure of your health information. The Entity is required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of its legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• Notify you following any breach of your unsecured PHI as required by law.

The Entity is also required by law to provide you with adequate notice of your rights and its legal duties if it creates or maintains records protected by 42 C.F.R. Part 2.

The Entity can change the terms of this Notice, and such changes will apply to all information it has about you. The new Notice will be available upon request, at the office, and on the website.

II. How the Entity May Use and Disclose Health Information About You

The following categories describe different ways that the Entity uses and discloses health information. For each category of uses or disclosures, this notice explains what is meant and gives some examples. Not every use or disclosure in a category will be listed. However, all of the ways the Entity is permitted to use and disclose information will fall within one of the categories.

Treatment, Payment, and Health Care Operations: Federal privacy law permits the Entity to use and disclose protected health information (“PHI”), without your written authorization, for certain treatment, payment, and health care operations activities. The Entity may use your PHI internally as reasonably necessary to provide and coordinate your care and to perform authorized clinical, administrative, billing, compliance, and practice-management functions.

Although HIPAA may permit the Entity to disclose your PHI to another health care provider for that provider’s treatment activities without your written authorization, it is the Entity’s policy ordinarily to obtain your written authorization before voluntarily disclosing identifiable clinical information to an outside health care provider for treatment or care-coordination purposes. This includes communications with your physician, psychiatrist, former therapist, or another outside treating professional.

This policy does not prevent the Entity from using or disclosing PHI without authorization when the disclosure is required by law or otherwise necessary and permitted in circumstances such as a medical or psychiatric emergency, a serious threat to health or safety, suspected abuse or neglect, a valid court order, or another legally recognized exception described in this Notice.

The Entity may also use and disclose the minimum PHI reasonably necessary for payment and health care operations, including verifying insurance eligibility and benefits; obtaining authorization; submitting and correcting claims; responding to requests concerning coverage, medical necessity, utilization review, claim appeals, quality review, fraud prevention, or payer audits; and performing billing, legal, compliance, and practice-administration activities. These disclosures generally do not require a separate written authorization.

Substance Use Disorder Records: If the Entity receives or maintains substance use disorder treatment records that are protected by 42 C.F.R. Part 2, additional federal confidentiality protections apply. Certain uses and disclosures of those records require your written consent unless another specific provision of law permits the use or disclosure. When Part 2 records are disclosed pursuant to a valid consent for treatment, payment, or health care operations, a HIPAA-regulated recipient may be permitted to use and redisclose the information as allowed by HIPAA. However, Part 2 records generally may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you without your specific written consent or a qualifying court order and subpoena. Other restrictions may also apply.

Additional protections under California law: California law may provide greater protection than HIPAA for certain information, including information concerning treatment of minors, immigration status or place of birth, reproductive health care, gender-affirming care, mental health treatment, and other specially protected information. The Entity will comply with the more protective applicable law.

Lawsuits, Subpoenas, and Legal Proceedings: A subpoena, discovery request, or demand from an attorney does not by itself authorize the Entity to disclose your records. The Entity will disclose records or testimony in connection with a lawsuit or other legal proceeding only when you (or your personal representative) authorize it in writing, when required by a valid court or administrative order, or when otherwise permitted or required by applicable law, including any required efforts to notify you of the request or to obtain an order protecting the information. When appropriate, your treating clinician or the Entity may assert the psychotherapist-patient privilege on your behalf. Records protected by 42 C.F.R. Part 2, or testimony relaying their content, will not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless you provide specific written consent or a court order is issued in accordance with 42 C.F.R. Part 2.

III. Certain Uses and Disclosures Require Your Authorization

1. Psychotherapy Notes. Your treating clinician may 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 use by the clinician who created the notes in treating you.
   • For use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
   • For use in defending the Entity or your clinician in legal proceedings instituted by you.
   • For use by the Secretary of Health and Human Services to investigate the Entity’s compliance with HIPAA.
   • Required by law and 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.
   • Required to help avert a serious threat to the health and safety of others.
2. Substance Use Disorder (SUD) Counseling Notes. The Entity may also maintain “SUD counseling notes,” which are notes recorded by a substance use disorder provider documenting the contents of a counseling session. Any use or disclosure of these notes requires your separate written authorization, which cannot be combined with a consent for other types of records. You can revoke your consent at any time except to the extent that the Entity has already acted upon it to disclose these notes in accordance with your initial authorization.
3. Marketing Purposes. The Entity will not use or disclose your PHI for marketing purposes.
4. Sale of PHI. The Entity will not sell your PHI.

IV. Certain Uses and Disclosures Do Not Require Your Authorization

Subject to certain limitations in the law, the Entity can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. 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.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order, as described in Section II above. The Entity’s preference is to obtain an Authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on the Entity’s premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. 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.
8. For workers’ compensation purposes. Although the Entity’s preference is to obtain an Authorization from you, it may provide your PHI in order to comply with workers’ compensation laws.
9. Appointment reminders and health related benefits or services. The Entity 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 it offers.

V. Certain Uses and Disclosures Require You to Have the Opportunity to Object

1. Disclosures to family, friends, or others. By law, the Entity 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. However, it is the Entity’s practice to obtain written authorization before disclosing PHI to your contacts, unless disclosure is required in an emergency situation. The opportunity to consent may be obtained retroactively in emergency situations.

VI. You Have the Following Rights With Respect to Your PHI

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask the Entity not to use or disclose certain PHI for treatment, payment, or health care operations purposes. Except as described in the next item, the Entity is not required to agree to your request, and may say “no” if it believes the restriction would affect your health care.
2. The Right to Restrict Disclosures to Your Health Plan for Services Paid in Full. If you pay for a health care item or service out-of-pocket in full, you can ask the Entity not to disclose information about that item or service to your health plan for payment or health care operations purposes. The Entity must agree to that request unless the disclosure is required by law.
3. The Right to Choose How the Entity Sends PHI to You. You have the right to ask the Entity to contact you in a specific way (for example, home or office phone), or to send mail to a different address, and the Entity will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes” and “SUD counseling notes,” you have the right to get an electronic or paper copy of your medical record and other information the Entity has about you. The Entity will provide you with a copy of your record, or a summary of it if you agree to receive a summary, within 15 days of receiving your written request, and may charge a reasonable, cost-based fee for doing so.
5. The Right to Get a List of the Disclosures the Entity Has Made. You have the right to request a list of instances in which the Entity has disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided an Authorization. The Entity will respond to your request for an accounting of disclosures within 60 days of receiving it. The list will include disclosures made in the last six years unless you request a shorter time. The Entity will provide the list at no charge, but if you make more than one request in the same year, it will charge a reasonable cost-based fee for each additional request. To the extent required by applicable law, you may also have the right to request an accounting of disclosures specifically for your substance use disorder records protected under 42 C.F.R. Part 2.
6. The Right to Be Notified in the Case of a Breach of Unsecured PHI.
7. 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 the Entity correct the existing information or add the missing information. The Entity may say “no” to your request, but will tell you why in writing within 60 days of receiving it.
8. 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. Even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

File a complaint if you feel your rights are violated

You can complain if you feel your rights have been violated by contacting the Security Officer using the contact information at the top of this notice.

You can 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 visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html.

The Entity will not retaliate against you for filing a complaint.

Acknowledgement of Receipt

When you begin services, you will be asked to acknowledge that you received a copy of this Notice of Privacy Practices.