Clinical Services Privacy Policy

Common Ground Grief Support

A dba of Forward Endeavors, a 501(c)(3) organization (EIN 93-4248727)

437 W. Willow St., Long Beach, CA 90806

Last updated: July 16, 2026

Your Information. Your Rights. Our Responsibilities.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Common Ground is required by federal and California law to maintain the privacy and security of your Protected Health Information (“PHI”). PHI is information that identifies you and relates to your past, present, or future physical or mental health condition and related care or payment for care.

We are required to:

Maintain the privacy of your PHI
Provide you with this Notice of our legal duties and privacy practices
Follow the terms of this Notice currently in effect
Notify you if a breach occurs that may compromise the privacy or security of your PHI

Where California law provides greater privacy protections than federal law, we follow the more protective California standard.

YOUR RIGHTS

You have the following rights regarding your PHI:

1. Right to Inspect and Receive a Copy

You may request access to inspect or receive an electronic or paper copy of your medical record and other PHI. We may charge a reasonable, cost-based fee consistent with California law.

We may deny access in limited circumstances permitted by law, including if a licensed professional determines that access may pose a substantial risk of harm. You may request a review of certain denials.

2. Right to Request an Amendment

If you believe your PHI is incorrect or incomplete, you may request a written amendment. We may deny the request in accordance with law but will provide a written explanation and allow you to submit a statement of disagreement.

3. Right to Request Confidential Communications

You may request that we contact you in a specific way (for example, at a specific phone number or address). We will accommodate reasonable requests.

4. Right to Request Restrictions

You may request restrictions on how we use or disclose your PHI for treatment, payment, or health care operations. We are not required to agree unless:

You pay for services in full out-of-pocket, and
You request that we not disclose the information to your health plan.

If those conditions are met, we will comply unless disclosure is required by law.

You may also request restrictions regarding disclosure to family members or others involved in your care.

5. Right to an Accounting of Disclosures

You may request a list of certain disclosures made outside of treatment, payment, and operations. One accounting per 12-month period is free. Additional requests may involve a reasonable fee.

6. Right to Receive a Paper Copy of This Notice

You may request a paper copy at any time, even if you agreed to receive it electronically.

7. Right to Choose Someone to Act for You

If you have a medical power of attorney or legal guardian, that person may exercise your rights consistent with applicable law.

8. Right to File a Complaint

If you believe your privacy rights have been violated, you may file a complaint with:

Common Ground Privacy Officer
437 West Willow St.
Long Beach, CA 90806
(562) 548 - 8078

You may also file a complaint with:

U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-800-368-1019
www.hhs.gov/ocr/privacy/hipaa/complaints

We will not retaliate against you for filing a complaint.

HOW WE MAY USE AND DISCLOSE YOUR INFORMATION

We may use and disclose your PHI without your written authorization for the following:

1. Treatment

To provide, coordinate, or manage your health care.
Example: Sharing information with another provider involved in your treatment.

2. Payment

To obtain payment for services rendered.

3. Health Care Operations

For administrative and operational activities such as quality assessment, compliance, auditing, licensing, and business planning.

OTHER PERMITTED OR REQUIRED DISCLOSURES

We may disclose PHI without authorization when required or permitted by law, including:

Public health reporting
Health oversight activities
Judicial or administrative proceedings
Law enforcement requests
Reporting abuse, neglect, or domestic violence
To avert a serious threat to health or safety
Workers’ compensation
Coroners or medical examiners
Research approved by an institutional review board
Specialized government functions

DISCLOSURES TO FAMILY OR OTHERS INVOLVED IN CARE

Unless you object, we may share relevant PHI with family members or others involved in your care or payment for care.

If you are unable to state your preference, we may disclose information if we determine it is in your best interest.

USES REQUIRING WRITTEN AUTHORIZATION

We must obtain your written authorization for:

Marketing communications (where required by law)
Sale of PHI
Use or disclosure of psychotherapy notes
Certain disclosures of specially protected information

You may revoke your authorization in writing at any time.

SUBSTANCE USE DISORDER RECORDS (42 CFR PART 2)

If we maintain records subject to 42 C.F.R. Part 2, additional confidentiality protections apply.

Such records may not be disclosed without your specific written consent except in limited circumstances permitted by law, including medical emergencies, certain research activities, audits, and court orders.

Redisclosure may be prohibited without additional consent as required by federal law.

CALIFORNIA-SPECIFIC PROVISIONS

Confidentiality of Medical Information Act (CMIA)

We comply with California’s Confidentiality of Medical Information Act, which provides additional protections beyond HIPAA.

Mental Health Records

We comply with California mental health privacy laws, including the Lanterman-Petris-Short Act and related statutes.

Psychotherapy notes are defined narrowly under HIPAA and are maintained separately when required.

Minor Consent (California Law)

Under California law, minors age 12 and older may consent to certain mental health services if statutory criteria are met.

When a minor lawfully consents to treatment:

Parental access to records may be restricted.
We may deny parental access if a licensed provider determines that access would have a detrimental effect on the minor’s therapeutic relationship or safety, as permitted by California law.

When parents or guardians have legal authority to access records, we will comply unless limited by law or court order.

Genetic Information

We do not use or disclose genetic information for underwriting purposes.

Sale of Medical Information

We do not sell your medical information.

ELECTRONIC COMMUNICATIONS

If you choose to communicate with us via email, text message, or other electronic methods, there may be risks to privacy due to the nature of electronic communication.

By requesting or using such communication methods, you acknowledge and accept these risks.

WEBSITE PRIVACY

Our Notice of Privacy Practices applies to PHI maintained by our Practice. For information about how we collect and use information through our website or digital platforms, please review our separate Website Privacy Policy available at:

www.commongroundgrief.org/privacy-policy

OUR RESPONSIBILITIES

We are required to:

Maintain the privacy and security of PHI
Follow the terms of this Notice
Comply with stricter state or federal privacy laws
Provide notice of changes

We reserve the right to revise this Notice. Revised notices will apply to all PHI we maintain and will be available in our offices and on our website.

ORGANIZED HEALTH CARE ARRANGEMENT

This Notice applies to Common Ground, affiliated professional entities, and providers who participate in an organized health care arrangement with us, where applicable.

This Notice is effective 07/21/2026