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 READ IT CAREFULLY.
If you have any questions about this notice, please contact the Risk and Compliance Department at (530) 674-4261, 935 Market Street, Yuba City, CA 95991.
WHO WILL FOLLOW THIS NOTICE
This notice describes information about privacy practices followed by our employees, staff and other office personnel. The practices described in this notice will also be followed by healthcare providers you consult with by telephone (when your regular healthcare provider from our office is not available) who provide “call coverage” for your healthcare provider. This notice is effective April 14, 2003, and applies to all protected health information as defined by federal regulations.
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about your health, health status, and the healthcare and services you receive at this office. We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We must have your signed Consent to use and disclose health information for the following purposes:
For Treatment. We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you and your health.
For example, your doctor may be treating you for a heart condition and may need to know if you have other health problems that could complicate your treatment. The doctor may use your medical history to decide what treatment is best for you. The doctor may also tell another doctor about your condition so that doctor can help determine the most appropriate care for you.
Different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions to our pharmacy, scheduling lab work and ordering X-rays. Family members and other healthcare providers may be part of your medical care outside this office and may require information about you that we have.
For Payment. We may use and disclose health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a service you received here so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will cover the treatment.
For Healthcare Operations. We may use and disclose health information about you in order to run the office and make sure that you and our other patients receive quality care. For example, we may use your health information to evaluate the performance of our staff in caring for you. We may also use health information about all or many of our patients to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective.
Appointment Reminders. We may contact you as a reminder that you have an appointment for treatment or medical care at the office. We may leave a message on your answer machine or on voicemail as a means of communication. We may mail you a postcard or written notice as a means of communication. We may also notify you via email or the patient portal.
Treatment Alternatives. We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health–Related Products and Services. We may tell you about health-related products or services that may be of interest to you.
Please notify us if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about treatment alternatives or health-related products and services. If you advise us in writing (at the address listed at the top of this Notice) that you do not wish to receive such communications, we will not use or disclose your information for these purposes.
You may revoke your Consent at any time by giving us written notice. Your revocation will be effective when we receive it, but it will not apply to any uses and disclosures that occurred before that time.
If you do revoke your consent, we will not be permitted to use or disclose information for purposes of treatment, payment or healthcare operations, and we may therefore choose to discontinue providing you with healthcare treatment and services.
SPECIAL SITUATIONS
We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:
To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Required By Law. We will disclose health information about you when required to do so by federal, state or local law.
Research. We may use and disclose health information about you for research projects that are subject to a special approval process. We will ask you for your permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the office.
Organ and Tissue Donation. If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate such donation and transplantation.
Military, Veterans, National Security and Intelligence. If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
Public Health Risks. We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, nonaccidental physical injuries, reactions to medication or problems with products.
Health Oversight Activities. We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the healthcare system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order, Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.
Law Enforcement. We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
Information Not Personally Identifiable. We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Family and Friends. We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the exam room during treatment or while treatment is discussed.
In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. For example, we may inform the people who accompanied you to the emergency room that you suffered a heart attack and provide updates on your progress and prognosis. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, filled prescriptions, medical supplies, or X-rays.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. We must obtain your Authorization separate from any Consent we may have obtained from you. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time pursuant to 45 CFR I64.508(b)(5). If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.
If we have HIV or substance use information about you, we cannot release that information without a special signed, written Authorization (different than the Authorization and Consent mentioned above) from you. In order to disclose these types of records for purposes of treatment, payment or healthcare operations, we will have to have both your signed Consent and a special written Authorization that complies with the law governing HIV or substance use records. The Privacy Rule states that if you have any psychotherapy notes, they will be disclosed only with written authorization.
The use and disclosure of your protected information for marketing purposes also requires authorization.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy. You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care. You must submit a written request to our Risk and Compliance Department in order to inspect and /or copy your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and / or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed healthcare professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
Right to Amend. If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office. To request an amendment, complete and submit a Medical Record Amendment/Correction Request Form to our Risk and Compliance Department.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment and healthcare operations. To obtain this list, you must submit your request in writing to our Risk and Compliance Department. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list for example, on paper or electronically. We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. Pursuant to 45 CFR 164.522(a)(l)(vi) you may request that Ampla Health not disclose certain PHI to health plans when the individual pays out of pocket in full for a healthcare service or item.
We are Not required to Agree to Your Request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you may complete and submit the Request For Restriction On Use/Disclosure of Medical Information to our Risk and Compliance Department.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, by mail or by email. To request confidential communications, you may complete and submit the Request for Restriction on Use/Disclosure Of Medical Information and/or Confidential Communication to our Risk and Compliance Department. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact our Risk and Compliance Department.
Breach of Protected Health Information.
45 CFR 164.520(b)(l)(v)(A) requires Ampla Health to notify any and all patients that have been affected by a security breach of their PHI.
CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date in the bottom right-hand corner. You are entitled to a copy of this notice currently in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201. To file a complaint with our office, contact our Risk and Compliance Department at 935 Market Street, Yuba City, CA 95991. You will not be penalized for filing a complaint.
NOTICE OF PRIVACY PRACTICES-SUD ADDENDUM
(42 CFR Part 2: Substance Use Disorder Records)
This notice describes:
- HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
- YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
- HOW TO FILE A COMPLAINT CONCERNING A VIOLATION OF THE PRIVACY OR SECURITY OF YOUR HEALTH INFORMATION, OR OF YOUR RIGHTS CONCERNING YOUR INFORMATION
YOU HAVE A RIGHT TO A COPY OF THIS NOTICE (IN PAPER OR ELECTRONIC FORM) AND TO DISCUSS IT WITH THE RISK AND COMPLIANCE DEPARTMENT AT (530) 674-4261/Compliance@amplahealth.org IF HAVE ANY QUESTIONS.
Effective Date: February 16, 2026
This SUD Addendum explains how Ampla Health protects Substance Use Disorder (SUD) treatment information under 42 CFR Part 2, which provides protections that are more strict than standard HIPAA (Health Insurance Portability and Accountability Act) privacy laws. These protections apply to records created by our Medication-Assisted Treatment (MAT) and Substance Use Disorder counseling programs.
This Addendum should be read together with the full Notice of Privacy Practices (NPP).
1. What Information Is Protected Under Part 2
Part 2 protects any information that:
- Identifies you as receiving SUD/MAT services at Ampla Health
- Is created, received, or maintained by our SUD/MAT program
- Includes diagnosis, counseling notes, assessments, treatment plans, medications, urine drug testing, or appointment details related to addiction treatment
This information is called a Part 2 Record.
2. Uses and disclosures
We cannot release your SUD information without your written consent, unless a specific Part 2 exception applies.
With your signed consent, your SUD information may be shared for:
- Your medical care and treatment
- Care coordination between your providers
- Billing and payment activities
- Referrals to outside providers or programs
- Emergency contact support if you designate someone
Your consent may be revoked at any time unless Ampla Health has already acted on it.
3. When Your SUD Information Can Be Shared Without Consent
Federal law allows limited disclosures without written consent only in these situations:
- Medical emergency: If you are experiencing a medical crisis and your SUD history is needed for safe care
- Audit or evaluation: To authorized auditors, government agencies, or accreditation bodies
- Qualified Service Organizations (QSOs): Contractors that provide services (e.g., labs, billing vendors) who are bound by Part 2
- Mandatory reporting: Situations required by law, such as suspected child or elder abuse
- Crimes on program premises or against program staff
- Court order: Only by specific court order that meets strict Part 2 requirements. No other disclosures are allowed.
4. Prohibition on Redisclosure (Very Important)
If we share your SUD information with your consent or as permitted by law, the recipient is legally prohibited from redisclosing it unless:
- You sign a new written consent, or
- Federal law (42 CFR Part 2) specifically allows it
Any permitted disclosure must include the following statement:
“This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). Federal law prohibits you from making any further disclosure without the specific written consent of the person to whom it pertains, or as otherwise permitted by 42 CFR Part 2.”
5. Patient Rights Under Part 2
You have all HIPAA rights plus additional protection for SUD records:
- Right to request restrictions on who can receive your SUD information
- Right to revoke consent at anytime
- Right to an accounting of SUD disclosures made without your consent
- Right to receive a copy of this Addendum and the full NPP
- Right to file a privacy complaint without fear of penalty
6. How to Provide or Revoke Consent
You may authorize Ampla Health to share your SUD/MAT information by completing the:
“42 CFR Part 2-Compliant SUD Consent to Release Information” form
You may withdraw this consent at any time in writing.
7. Program duties for Part 2
This Program is required by law to maintain the privacy of records that are protected under 42 CFR Part 2, which applies to substance use disorder (SUD) treatment records. The Program is also required to provide patients with this Notice of Privacy Practices, which explains its legal duties and privacy practices with respect to those records. In addition, the Program is required to notify affected patients following a breach of unsecured Part 2-protected records, as required by law.
The Program is required to abide by the terms of this Notice of Privacy Practices that are currently in effect.
The Program reserves the right to change the terms of this Notice of Privacy Practices and to make the revised notice provisions effective for all Part 2-protected records that it maintains, including records created or received prior to the effective date of the revised notice. If the Program makes a material change to its privacy practices, it will provide patients with a revised Notice of Privacy Practices by posting the updated notice in a
prominent location at its facilities and/or on its website, and by making the revised notice available upon request.
8. Questions or Complaints
If you have questions about your privacy rights or believe your rights have been violated, contact:
Ampla Health – Privacy Officer
Attn: Harjit Jhikka, B.S., RHIA, CHC, CHPC
935 Market Street
Yuba City, CA 95991
Phone: (530) 674- 4261
Email: Compliance@amplahealth.org
You may also file a complaint with the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint.
Acknowledgment of Receipt
Patients will be asked to sign an acknowledgment that they received:
- The full Notice of Privacy Practices (NPP)
- This SUD Addendum
This acknowledgment will be provided electronically or in paper form during registration or the first MAT/SUD appointment.