Effective Date: March 1, 2026

​

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

A current version of this Notice of Privacy Practices is available at our facilities and on our website. Printed copies of this Notice are available upon request.

 

At Mensana Collaborative (“Practice”), we understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive directly from one of our physicians. These records may contain Protected Health Information (PHI). We need this record to provide you with quality care and to comply with certain legal requirements. This Notice of Privacy Practices (“Notice”) applies to all the records of your care generated by Mensana Collaborative.

This Notice will tell you about the ways in which Mensana Collaborative may use and disclose your PHI. PHI may exist in electronic, paper, or verbal form. This Notice also describes your rights and certain obligations Mensana Collaborative has regarding the use and disclosure of PHI. 

 

REGULATORY REQUIREMENTS

Mensana Collaborative is required by law to maintain the privacy of your PHI, to provide individuals with notice of Mensana Collaborative’s legal duties and privacy practices with respect to PHI, notify you following a breach of unsecured PHI when required by law, and to abide by the terms described in the Notice currently in effect.

 

APPLICABLE LAWS

Mensana Collaborative complies with:

• The Health Insurance Portability and Accountability Act (HIPAA)

• The Health Information Technology for Economic and Clinical Health Act (HITECH)

• The 21st Century Cures Act

• The California Confidentiality of Medical Information Act (CMIA)

• 42 CFR Part 2 protecting substance use disorder treatment records

• Other applicable federal and California privacy laws

 

When California law provides greater privacy protection, Mensana Collaborative follows California law.

 

RIGHTS

You have the following rights regarding your PHI:

 

Restrictions
You may request that Mensana Collaborative restrict the use and disclosure of your PHI. To request restrictions, you must make your request in writing to our Director of Clinical Operations using the applicable Mensana Collaborative form available through your Client Portal. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the restrictions to apply; for example, disclosures to your spouse. 

Alternative Communications
You have the right to request that communications of PHI to you from Mensana Collaborative be made by particular means or at particular locations. For instance, you might request that communications be made at your work address, instead of your home address. Again, your requests must be made in writing using Mensana Collaborative’s form and sent to the Director of Clinical Operations. Mensana Collaborative will accommodate your reasonable requests. 

Inspect and Copy

Generally, you have the right to inspect and copy your PHI that Mensana Collaborative maintains, provided you make your request in writing to Mensana Collaborative’s Director of Clinical Operations. If you request copies of your PHI, we may impose a reasonable fee to cover copying and postage. If we deny access to your PHI, we will explain the basis for denial and your opportunity to have your request and the denial reviewed by a licensed health care professional (who was not involved in the initial denial decision) designated as a reviewing official. If Mensana Collaborative does not maintain the PHI you request and if we know where that PHI is located, we will tell you how to redirect your request.

Amendment

If you believe that your PHI maintained by Mensana Collaborative is incorrect or incomplete, you may ask us to correct your PHI. Your request must be made in writing to the Director of Clinical Operations, and it must explain why you are requesting an amendment to your PHI. We can deny your request if your request relates to PHI: (i) not created by Mensana Collaborative; (ii) not part of the records Mensana Collaborative maintains; (iii) not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, we will provide you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that any future disclosures of the relevant PHI be made with a copy of your request and Mensana Collaborative’s denial attached; and (iii) complain about the denial.

 

Accounting of Disclosures

You generally have the right to request and receive a list of the disclosures of your PHI we have made at any time during the six (6) years prior to the date of your request (provided that such a list would not include disclosures made prior to April 14, 2003). The list will not include disclosures made at your request, with your authorization, and does not include certain uses and disclosures to which this Notice already applies, such as those: (i) for treatment, payment and health care operations; (ii) made to you; (iii) for Mensana Collaborative’s patient list; (iv) for national security or intelligence purposes; or (v) to law enforcement officials. You should submit any such request to Mensana Collaborative’s Director of Clinical Operations. Mensana Collaborative will provide the list to you at no charge, but if you make more than one request in a year you will be charged a fee of the costs of providing the list.

Right to Copy of Notice

You have the right to receive a paper copy of this notice upon request.  To obtain a paper copy of this notice, please contact the Director of Clinical Operations at the address and contact information stated at the end of this notice.

​

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

Mensana Collaborative may use or disclose your PHI for the purposes described below without obtaining written authorization from you.  In addition, Mensana Collaborative and the members of its medical and allied health professional staff who participate in the organized health care arrangement described below may share your PHI with each other as necessary to carry out their treatment, payment and health care operations related to the organized health care arrangement.

For Treatment

Mensana Collaborative may use and disclose PHI while providing, coordinating or managing your medical treatment, including the disclosure of PHI for treatment activities of another health care provider.

For Payment

Mensana Collaborative may use and disclose PHI to bill and collect payment for the health care services provided to you. For example, Mensana Collaborative may need to give PHI to you in order for you to be reimbursed for the services provided to you if you requested a Superbill.

For Health Care Operations

Mensana Collaborative may use and disclose PHI as part of its operations, including for quality assessment and improvements, such as evaluating the treatment and services you receive and the performance of staff and physicians in caring for you, patient surveys, provider training, underwriting activities, compliance and risk management activities, planning and development, credentialing and peer review activities, and health care fraud and abuse detection or compliance, and management and administration. Mensana Collaborative may disclose PHI to doctors, nurses, technicians, students, attorneys, consultants, accountants and others for review and learning purposes, to help make sure Mensana Collaborative is complying with all applicable laws, and to help Mensana Collaborative continue to provide quality health care to its patients.

As Required by Law and Law Enforcement

Mensana Collaborative may use or disclose PHI when required to do so by applicable laws and when ordered to do so in a judicial or administrative proceeding. Mensana Collaborative may also use or disclose PHI upon a properly documented and limited request from law enforcement agencies.

For Public Health Activities and Public Health Risks

Mensana Collaborative may disclose PHI to government officials in charge of collecting information about births and deaths, preventing and controlling disease, or notifying a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition.

For Health Oversight Activities

Mensana Collaborative may disclose PHI to the government for oversight activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, and other proceedings, actions or activities necessary for monitoring the health care system, government programs and compliance with civil rights laws.

Coroners, Medical Examiners and Funeral Directors

Mensana Collaborative may disclose PHI to coroners, medical examiners and funeral directors for the purpose of identifying a decedent, determining a cause of death or otherwise as necessary to enable these parties to carry out their duties consistent with applicable law.

 

Research

Under certain circumstances, Mensana Collaborative may use and disclose PHI for medical research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication with those who received another, for the same condition. 

 

To Avoid a Serious Threat to Health or Safety

Mensana Collaborative may use and disclose PHI to law enforcement personnel or other appropriate persons to prevent or lessen a serious threat to the health or safety of a person or the public.

 

Specialized Government Functions

Mensana Collaborative may use and disclose PHI of military personnel and veterans under certain circumstances. Mensana Collaborative may also disclose PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities, and for the provision of protective services to the president or other authorized persons or foreign heads of state or to conduct special investigations.

 

Disclosures to You or for HIPAA Compliance Investigations

Mensana Collaborative may disclose your PHI to you or to your personal representative and is required to do so in certain circumstances described below in connection with your rights of access to your PHI and to an accounting of certain disclosures of your PHI. Mensana Collaborative must disclose your PHI to the Secretary of the United States Department of Health and Human Services (the "Secretary") when requested by the Secretary in order to investigate Mensana Collaborative’s compliance with privacy regulations issued under the federal Health Insurance Portability and Accountability Act of 1996.

 

Disclosures to Individuals Involved in Your Health Care or Payment for Your Health Care

Unless you object, Mensana Collaborative may disclose your PHI to a family member, other relative, friend, or other person you identify as involved in your health care or payment for your health care.

 

OTHER USES AND DISCLOSURES.

Other types of uses and disclosures of your PHI not described above will be made only with your written authorization, which with some limitations, you have the right to revoke your authorization in writing. If you revoke your authorization, Mensana Collaborative will no longer use or disclose PHI about you for the reasons covered in your written authorization. Please understand that Mensana Collaborative is unable to recover any disclosures already made with your authorization, and that Mensana Collaborative is required to retain records of the care provided to you.

 

BREACH NOTIFICATION

If a breach occurs that compromises the privacy or security of your PHI, Mensana Collaborative will notify affected individuals, the U.S. Department of Health and Human Services, and, when required by law, select other parties following a breach of unsecured protected health information.

 

RIGHT TO FILE A COMPLAINT.

You may submit any complaint regarding your privacy rights to: 

Jeremiah Hindman

Director of Clinical Operations

Mensana Collaborative

3771 Rio Rd, Suite 111

Carmel, CA 93923

 

You also have the right to file a complaint with the Secretary of the Department of Health and Human Services, Office for Civil Rights.  You will not be penalized for filing a complaint. You may contact the Office for Civil Rights at:

Office for Civil Rights

U.S. Department of Health and Human Services

90 7th Street, Suite 4-100
San Francisco, CA 94103
Customer Response Center: (800) 368-1019
Fax: (202) 619-3818
TDD: (800) 537-7697
Email: ocrmail@hhs.gov