Effective date: August 17, 2004

LeRoy Haynes Center for Children and Family Services NOTICE OF PRIVACY PRACTICES



This notice describes Leroy Haynes Center for Children and Family Services practice and that of:

  • All employees, staff, independent contractors and other Leroy Haynes Center personnel
  • Any member of a volunteer group we allow to help us while you and/or your child are in this facility.


Privacy is a very important concern for all those who become enrolled in one of our treatment programs. We are committed to protecting medical information about you and/or your child. We create a record of the care and services you receive at our agency. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all records of your care generated by our agency. As required and when appropriate, we will ensure that the minimum necessary information is released in the course of our duties.

This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations regarding the use and disclosure of medical information.

We are required by law to:

  • Keep your medical information, also known as "protected health information" or "PHI" private.
  • Give you this Notice of our legal duties and privacy practices with respect to your PHI.
  • Follow the terms of the Notice that are currently in effect.


This Notice will tell you how we will handle your medical information or that same information on behalf of your child in treatment. It tells you how we use this information here at the Center, how we share it with other professionals and organizations, and how you can see it. We want you to know all of this so that you can make the best decisions for yourself and your family members. If you have any questions or want to know more about anything in this Notice, please ask a Clinical administrator or Privacy Officer for more explanations or more details.


When your information is read by someone at the Center involved in your treatment and care that is called in the law, "use." If the information is shared with or sent to others outside the Center, that is called, in the law, "disclosure." Except in some special circumstances, when we use your PHI here or disclose it to others we share only the minimum necessary PHI needed for those other people to do their jobs. For each category or uses or disclosures we will explain what we mean and give you some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment

In most all cases we intend to use your PHI here or share your PHI with other people or organizations to provide treatment to you. We create a record of the treatment and services you and/or your child receive at our agency. We may disclose your PHI to physicians, therapists, nurses or other agency personnel who are involved in your care. For example. A physician treating your child for Attention-Deficit Disorder may need to know if he/she has other medical conditions because this may determine what type of medication he/she will prescribe to your child. We may share your PHI in order to coordinate different services your child may need such as physical exams, laboratory tests and prescriptions, and to make a correct diagnosis.

We may share or disclose your PHI without your authorization to health care professionals who also provide treatment to you. We are likely to share your information with other health care professionals such as medical doctors, therapists, psychologists, and psychiatrists. If you are being treated by a team they can share some of your PHI with them so that the services you receive will be better coordinated and more effective. The other professionals treating you will also enter their findings, the actions they took, and their plans into your medical record and so we all can decide what treatments work best for you and develop an appropriate treatment plan. We may refer you to other professionals or consultants for services we cannot provide. When we do this we need to tell them some things about you and your conditions. We will get back their findings and opinions and those will go into your records here. If you receive treatment in the future from other professionals we can also share your PHI with them.

For Payment

We may use your information to arrange for payment for the services that are provided to you. In some cases, the source of funding for your services may require us to provide them information about your diagnoses, what treatments you have received and the changes we expect in your conditions. We will need to tell them about the times and dates of the services provided to you, your progress and other similar things.

For Health Care Operations

There are a few other ways we may use or disclose your PHI for what are called health care operations. For example, we may use your PHI to see where we can make improvements in the care and services we provide. We may be required to supply some information to some government health agencies so they can study the effectiveness of treatment and make plans for services that are needed. If we do, your name and personal information will be removed from what we send.

Treatment Alternatives and Health-related Services

We may use and disclose your PHI to tell you about or recommend possible treatments or alternatives that may be of help to you.

We may use and disclose your PHI to tell you about health-related benefits or services that may be of benefit to you.

Appointment Reminders

We may use and disclose your PHI to contact you as a reminder that you have an appointment for treatment or medical or medical care at our agency.

Individuals Involved in Your and/or your Child's Care or Payment for Care

We may disclose your and/or your child's PHI to a family member who is involved in your medical care or payment related to your health care, provided that you agree to this disclosure or we have given you an opportunity to object to this disclosure. However, if you are not available or are unable to agree or object, we will use our professional judgment to decide whether this disclosure is in your best interest.

Disaster Relief Purposes

We may disclose your PHI to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. We will give you an opportunity to agree to this disclosure or object to this disclosure, unless we decide that we need to disclose your PHI in order to response to the emergency circumstances.

Uses and Disclosures of PHI from Mental Health Records that don't require a Consent or Authorization

The law lets us use and disclose some of your PHI without your consent or authorization in some cases. Here are some examples of when we might have to share your information.

When required by Law

There are some federal, state, or local laws which require us to disclose PHI.

Workers Compensation

We may release your PHI for worker's compensation or similar programs.

Public Health and Safety Risks

We may disclose medical information about you and/or your child when report abuse or neglect of children, elders and dependent adults. We may also disclose medical information for public health activities aimed at controlling or preventing disease and preventing injury and disability.

Health Oversight Activities

We may disclose your PHI to a government agency for oversight activities required by law. These activities includes audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Lawsuits and Disputes

If you are involved in a lawsuit or legal proceeding we and we receive a subpoena, discovery request or other lawful process, we may have to release some of your PHI. We will do so only after trying to tell you about the request, consulting your legal counsel or trying to get a court order to protect the information they requested.

Coroners, Medical Examiners and Funeral Directors

We may release your PHI to a coroner or medical examiner for the purpose of identifying a deceased person or to determine the cause of death. We may also release medical information about clients of the agency to funeral directors as necessary to carry out their duties.

Law Enforcement

  • In response to a court order, warrant, subpoena, summons or similar process issued by a court.
  • When a minor who is a dependent of the court is unaccounted for or has AWOL'd from the agency.
  • When a mental health professional believes that a you and/or your child presents a serious danger of violence to another person.
  • When mental health professional believes that your, and/or, your child are at immediate risk of self-harm.
  • When you or your child is an inmate or under the custody of a law enforcement official, we may release PHI to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with medical care, to protect your health and safety or the health and safety of others and for the safety and security of the correctional institution.

Specialized Government Functions

We may disclose your and/or your child's PHI to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

We may disclose your and/or your child's PHI to authorized federal officials so that they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Uses and Disclosures of PHI that require your Authorization

If we want to use your information for any purposes besides treatment, payment or health care operations, we will need to obtain your permission on an Authorization form. This includes release of records to outside providers or health practioners. If you do authorize us to use or disclose your PHI, you can revoke (cancel) that permission, in writing, at any time. After that time we will not use or disclose your information for the purposes that we agreed to. Of course, we cannot take back any information we had already disclosed with your permission or that we had used at our Center

RIGHTS REGARDING YOUR PHI. You have the following rights regarding your PHI in our records:

Right to Inspect and Copy

With certain exceptions, you have the right to inspect and copy you or your child's PHI form our records.

To inspect and copy PHI that may be used to make decisions about you, you must submit a request in writing to the person in charge of your treatment. A form will be provided to you for this request... If you request a copy of your PHI, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your right to inspect and copy in certain circumstances. If you are denied the right to inspect and copy your Phi in our records, you may request that denial in writing, With the exceptions of a few circumstances that are not subject to review, another licensed health care professional at Leroy Haynes center, who was not involved in the denial, will review the decision. The agency will comply with the outcome of the review.

Right to Request Amendment

If you feel that your and/or your child's PHI in our records is incorrect or incomplete, you may ask is to amend the information. You have the right to request an amendment for as long as we keep the PHI.

Tot request and amendment, ask for a "Request to Amend Protected Health Information" form and complete and submit this form to the person in charge of your treatment. You must provide a reason that support's your request.

We may deny a your request for and amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend PHI that:

Was not created by us, unless you can provide us with a reasonable basis to believe that the person or entity that creased the PHI is no longer available to make to amendment; Is not part of the PHI kept by or for the facility;

Is not part of the PHI which you would be permitted to inspect or copy; or Is accurate and complete.

Even if we deny your request for amendment, you have the right to submit a Statement of Disagreement form, with a description not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want this form to be made part of your medial record, we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

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 your and/or your child's PHI other than our own uses for treatment, payment and health care operations and with other exceptions pursuant to the law.

To request this accounting of disclosures, ask for a "Request for Accounting of Disclosures" form and submit this form to the person in charge of your treatment. Your request must state a time period that may not be longer than six years and may not include dates before April 13, 2003. The first list you request in a 12-month period will be free. For additional lists, 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 we follow additional, special restrictions when using or disclosing you and/or your child's PHI for treatment, payment or health care operations. You also have the right to request that we follow additional, special restrictions when using or disclosing your PHI to someone who is involved in your and/or your child's care or the payment for health care, like a family member. For example, you could ask that we not use or disclose that you are receiving services at our agency.

We re not required to agree to your request. If we do agree, we will comply with your request unless the information is need to provide you or your child emergency treatment.

To request restrictions, ask for a "Request for Additional Restrictions on Use or Disclosure of Protected Health Information" and complete and submit this form to the person in charge of you and/or your child's treatment. In your request, you must tell us what information you want, whether you want to limit our use, disclosure or both, and to who you want the limits to apply(for example, disclosures to your spouse).

Right to Request Confidential Communications

You have the right to request that we communicate with you about your and/or your child's appointments or other matters related to treatment in a specific way or at a specific location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, ask for a "Request to Receive Confidential Communications by an Alternative Means or at Alternative Locations" form, and complete and submit this form to the person in charge of your treatment. Your request must specify how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.

You may obtain a copy of this Notice at our website: http//www.leroyhaynes.org.


We reserve the right to change the terms of this Notice. We have the right to make the revised or changed Notice effective for medical information we already have about you and/or your child as well as any information we receive in the future. A copy of the current Notice is posted at the agency; the effective date is on the first page of the Notice. If we change our Notice, you may obtain a copy of the revised Notice by visiting our website at http//www.leroyhaynes.org.


If you believe your privacy rights have been violated, you may file a complaint with us, the Los Angeles County Department of Mental Health or the Federal Government. Please note that all complaints must be submitted in writing. You will not be penalized or retaliated against for filing a complaint.

If you have any questions regarding this Notice or believe your privacy rights have been violated, please contact our Privacy Officer, Joy Gahring at

LeRoy Haynes Center
PO Box 400/233 W. Baseline Road
Laverne, CA 91750
(909) 593-2581 ext. 594

To file a complaint with the Los Angeles County Department of Mental Health, contact:
Los Angeles County Department of Mental Health Patient's Rights Division
550 South Vermont Avenue
Los Angeles, CA 90020
(213) 738-4949

To file a complaint with the federal Government, contact:
Region IX, Office for Civil Rights
U.S. Department of Health and Human Services
50 United Nations Plaza- Rom 322
San Francisco, CA 94102
Voice Phone: (415) 437-8310
Voice phone (415) 437 8329 FAX (415) 437-8329
TDD (415) 437-8311


Welcome to the LeRoy Haynes Center Web site. We've established this privacy policy because we respect the privacy of visitors to our site. Please read this policy carefully because we want you to understand the types of information collected on our Web site, the ways in which that information is used and protected, and the choices you have about collection of that information.

We do not collect personally identifiable information from individuals unless they provide it to us voluntarily and knowingly. If you register to use various features of our site, we use the information you supply for the purpose of providing the services you've requested. We may also contact you from time to time with information that relates to your requests or interests.


LeRoy Haynes Center collects two types of information: personal voluntary registration information, such as name and email address, and non-personal statistical information, such as site traffic and usage patterns.


This information is used primarily to deliver requested information, and to improve the design and structure of the site. It is used solely by LeRoy Haynes Center and others involved in the operation of this Web site and will never be sold or given to third parties.


To protect your privacy, we use technologies and processes such as encryption, access control procedures, network firewalls, physical security and other measures. In addition, we allow only authorized employees or agent's access to personal information. Although we cannot guarantee there will be no unauthorized access to personal information, these measures increase the security and privacy of information traveling to, from and within www.leroyhaynes.org.


LeRoy Haynes Center is not responsible for content, policies, and practices of other Web sites that are accessible by hyperlink from our site. LeRoy Haynes Center's privacy policy applies only to information maintained by LeRoy Haynes Center. In addition, LeRoy Haynes Center is not responsible for the materials contained at any Web site linked to our site.


We discourage any links to pages within our site other than our home page. We do not take responsibility for any pages that may no longer exist or are outdated, or for content that may no longer be accessible on our site.


Although we work very hard to provide the user with the most current and accurate information, we can't and don't warrant that everything you see on this site is up-to-date, error free, or complete. While we may periodically add, modify, or delete any of the content, we don't make any commitment or assume any obligation or duty to do so. The user should assume that the information is current and up-to-date only as of the date it is posted to this site. Any item with a fee or cost associated may be subject to change at any time, and without prior notification.


Should you have any questions or concerns about this privacy policy, please contact us by mail, telephone, or email at the addresses listed below:

LeRoy Haynes Center
233 W. Baseline Road, Box 400
La Verne, CA 91750-0400
(909) 593-2581


If LeRoy Haynes Center makes any changes to this policy, we will post them on this page. Please check back here periodically, as we will post changes without notice.